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It's time for a Plain English Directorate.
[ by Niall Hunter, Editor www.irishhealth.com]
On paper, Dr James Reilly's plans to restructure the HSE constitiute a very good idea. But then again, so were most recent plans to improve our health service, until it came to actually implementing, or not implementing them.
Just ask Fianna Fail leader Micheal Martin, who this week complained loudly about Dr Reilly's HSE revamp.
Someone should ask the former Health Minister sometime to do a doctoral thesis on the inverse relationship between the amount of reports produced and their impact on real change in the health service.
When you read the ultimate aims of Dr Reilly's restructuring of the HSE into an organisation run by seven new directorates you can't really disagree with them. It's like the Pope coming out against sin as as a bad thing, generally speaking.
The titles of the existing HSE directorates, regardless of the good work undoubtedly done by many in them, seem to bear little relation to providing better patient care and instead rather lovingly embrace abstract health managerial concepts.
These include 'integrated services'; 'corporate planning'; 'clinical programmes' and 'internal audit.' One can indeed empathise with Dr Reilly's statement at the launch of the restructuring that the perception of the health service is that it is self-serving rather than patient-serving.
The titles of the new directorates, in a shock move, actually bear some relationship to providing patient care- primary care, mental health, hospital care, social care etc.
It tells you a lot about what has been wrong up to now to learn that previously, there have never been directorates for mental health or primary care, despite the huge proportion of daily healthcare provision taken up by these areas.
So what, according to the Minister will actually happen when his reforms are put in place?
'Real visibility on service budgets'. Sounds good. But it's sometimes difficult to see things that, thanks to our little Celtic Tiger mishap and the demands of the Troika, are constantly shrinking in size.
'Service reform'. Again no objections there. But is this ever going to be delivered in a way we can all see and experience? And haven't we heard the mantra again and again, from the current and previous Ministers, with little sign of any real change on the horizon?
'Structural reform'. The new directorates, we are told 'will oversee the introduction of a purchaser- provider split' in the health system. We are reminded here of the old joke about the first item on the agenda of any new organisation in Ireland being a split.
However, this would merely be an attempt to distract from the fact that it is not really clear what 'purchaser-provider split' actually means. It is in all likelihood, related to the 'money follows the patient' system, under which the State will purchase certain types of care from healthcare agencies.
And there lies a key problem with Dr Reilly's brave new reform process. While the ultimate aim - universal health insurance, no two-tier system and equal access for all to healthcare, is laudable and easy to grasp, the process of getting to that point appears incredibly complex, cumbersome and difficult to explain to the public.
The case for the establishment of a HSE directorate of plain English is beginning to look very convincing.
In the meantime, the jury is going to be seconded to a local hotel for some time to decide on whether or not Dr Reilly's plans will actually work if they are ever fully implemented.
It is tempting at this stage to go into a detailed analysis of how the reforms will impact on patient care.
One is deterred from doing so, not only from an altruistic desire not to bore the reader too much, but also from fact that, whisper it loudly, nobody really knows the answer at this stage. Mainly because the progress of the reforms up to the introduction of universal health insurance in 2016 have yet to be fully explained.
Minister Reilly himself, when queried about how it's all going to work, tends to 'off-road' into soundbites about the Special Delivery Unit, money stalking the patient, care being delivered locally at the lowest level of complexity, patient-centredness etc.
At this stage the reform process has a number of worrying aspects.
Firstly, Dr Reilly has lost the services of HSE CEO Cathal Magee, who feels surplus to requirements in the Minister's HSE revamp and probably didn't feel like applying for a new job of Director General that sounded rather like his old job.
His departure is a pity, as Mr Magee has been an able administrator during very challenging times for the organisation, and could have been of some assistance to the Minister as major changes took place.
There were signs that the outgoing CEO was frustrated by the pressure from the Department to make further savings and efficiencies against a background of increasing care demands and shrinking budgets, and a veto by the Government on making any politically controversial bed or other service cuts.
Mr Magee pointed out that a proposal to cut agency staff expenditure would simply impact on already reduced staffing levels and might result in further bed closures.
There is no guarantee that these political-managerial tensions will simply disappear with the advent of new HSE structures.
Incidentally, Lady Bracknell-like, Dr Reilly has also lost the chairman and CEO of the VHI - this could all be coincidence of course.
Secondly, the massive revamp into seven directorates is only a temporary measure. It will be introduced before the end of this year and may only be in place for less than two years, as the HSE is due to be abolished completely in 2014.
It is due then to be replaced by an integrated care agency, with other former HSE functions transferred to the Department of Health, as a precursor the bright new dawn of universal health insurance in 2016. How all this is going to pan out is anybody's guess at this stage, as there is very little detail available.
It seems like a hell of a lot of trouble to go to to revamp an organisation that is due to be abolished very shortly in any case.
The third question is, to paraphrase the old lightbulb joke - how many managers does it take to run a health service, reformed or otherwise? Well...lots and lots of them, it appears.
The Minister will appoint the new Director General of the HSE under the new structures, probably from outside the organisation. The other new directors will be appointed through competition.
It also appears that most of the existing 11 directorates in the HSE may in any case continue to exist under the new system, operating under the seven new 'super-directorates.'
It will be difficult for the Minister to try to convince us that the new system will be leaner and meaner when the signs are that the tendency towards self-perpetuating bureaucracy is simply continuing.
And finally, however much the Minister might tell us that the new system will provide value for money, thanks to the Troika there will be less and less money to get value from as our bail out progresses - €2.5 billion taken out of the health service over three years and perhaps another half billion and counting next year, and heaven knows how much in 2014.
Incidentally, isn't the Troika complaining about things like the HSE's deficit and the unemployment rate a bit like a murderer complaining that the stab wounds they have inflicted on the victim are staining the carpet?
Most people will welcome the Minister's vision of a more equal health system. But lately, the vision has been getting a bit blurry.
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