Maeve Sheehan: Wards face closure as the HSE swings in wind of change
The Health Minister's bold plans have left more questions than answers
Published 27/10/2013 | 01:55
LIKE many utopian ideals, James Reilly's vision for the health service has been strong on rhetoric and short on forensic detail.
Before becoming Minister for Health he talked about a world where, under Fine Gael, hospital waiting lists and the Health Service Executive (HSE) would be no more.
He has promised a system of universal health insurance in which every citizen would have equal access to the best hospital and primary care.
According to his promises, those who can afford it will pay. Those who can't will be subsidised by the State. Money will follow the patient, in and out of hospital, incentivising hospitals to be lean, efficient and very patient-centred. And everyone will have access to free GP care.
The minister has tinkered around this vision since he took up his ministerial role. But, as years pass, has the minister simply taken down the scaffolding of the health service to leave the building exposed?
When Dr Reilly took the health portfolio in April 2011, the HSE was already in its sixth year. It had many problems, including staff, money and was completely lacking in public confidence.
It was a monolithic structure of more than 100,000 employees. Many were health board bureaucrats subsumed into the agency because no politician would fire them. Some didn't know what their jobs were, roles were duplicated. Even the HSE's own director of HR said there were too many managers.
It wasn't all bad. When Reilly came on the scene, a programme of cost cutting and efficiency was already under way. Half of the recommendations contained in the Brennan report – the template for the HSE – had been enacted.
Savings came in the form of bulk-buying and making suppliers tender for contracts. A sick leave drive reduced absenteeism rates from 7 per cent to 4.7 per cent.
The Croke Park deal was allowing immovable public sector staff to be redeployed where they were needed. A new national director, Cathal Magee, was embarking on the next phase of reform started by his predecessor, Professor Brendan Drumm.
More importantly, given the current straitened circumstances of the health service, the HSE – overseen by an independent board of directors – was coming in on budget. Enter Dr Reilly in April 2011. He took his first steps towards implementing his vision for universal healthcare by standing down the HSE's independent board.
He parachuted in top civil servants and effectively took control back into the Department of Health.
He launched a paper outlining his plans for universal health insurance that was notably short on detail.
This year he reorganised hospitals into regional groups, which will eventually become independent, not for profit hospital trusts. The theory is that each group of hospitals will offer a range of services to its catchment area of patients.
Next year, he plans to abolish the HSE.
A spokesman for Dr Reilly listed seven key areas which the Minister has progressed, including universal health insurance, restructuring, and establishing a patient-safety agency, along with related actions in cancer-screenings, and on drug costs which will generate savings of €50m this year.
But many questions remain about Dr Reilly's plans.
For instance what of the HSE's 100,000-odd employees? Will they still be public servants? Who will their new employer be? Will they still be governed by the Croke Park Agreement? Will any jobs be lost during this streamlining of hospital services? Where will all the managers go? Will insurers negotiate directly with hospitals on the price of medical procedures? Or will the Government impose the tariff on the hospitals?
How much will insurance premiums cost for those who have to pay? And how much will it cost the State to subsidise them?
There are many who believe that the Dr Reilly's plans may not come to pass.
Initially, he and his new HSE director general Tony O'Brien claimed their aim was to get everything in place by 2016, beginning with free GP visits for patients on high-tech drugs – such as medicines taken by transplant patients to help them accept new organs – by 2014.
But the only strategic precursor of universal health insurance in place at the moment is the free GP visits for children aged five and under. Experts have suggested it will be almost a decade before the plan for universal health insurance is up and running. And even then there are no guarantees that the current Government will be re-elected to see the plan through. There isn't any guarantee that successive administrations will embrace it either. Until such time as Dr Reilly's plan starts to take shape, what is left of the country's health systems is swinging in the wind.
Meanwhile, the Government has to take €666m out of the health system next year. That's on top of a HSE deficit of €105m, which could rise to €200m by year's end.
Separately, O'Brien has talked about another €350m the HSE will have to find to roll out safety measures in the wake of the death by medical misadventure of Savita Halappanavar – things that weren't factored into the budget.
The Troika, the HSE, and his cabinet colleague Brendan Howlin, have laid part of the blame at Dr Reilly's door.
Savings targeted by his department have failed to materialise. The €150m savings from staff efficiencies under the Haddington Road Agreement are expected to be €50m short. An estimated €60m was expected to stream into the health services from private health insurance companies paying for patients in public beds.
But it, too, has failed to materialise because the legislation was postponed. Millions in targeted drugs savings have fallen short – although Dr Reilly did deliver €125m last year.
Demand for health services has never been higher. Hospitals are running over budget, while waiting lists for some procedures have trebled. The Health Services Action Group has predicted ward, theatre and clinic closures in the run-up to Christmas as hospitals try to come in within budget.
When Dr Reilly dismantled the HSE board, he was accused of running "a coach and horses" through corporate governance by undermining the independence of the health executive. Billy Kelleher, who was Fianna Fail's spokesman on health, asked: "Will this be a board that is serving a political master?" Some of Dr Reilly's actions to date have highlighted the very dangers of leaving politicians in charge of the roll-out of health services.
He has been mired in three political scandals relating to his alleged interference in where services should go.
He he has been accused of "stroke politics" after bumping up primary care centres in his own constituency to the top of the queue – a scandal that triggered the resignation of his Labour junior minister, Roisin Shortall.
He was accused of fast-tracking development funding for hospitals in the constituencies of his cabinet colleagues, Phil Hogan and Brendan Howlin.
And he was again in bother when it emerged that €300,000 of autism funding was allocated to a service next to his constituency.
For now, the health service is back in the maw of politicians, plunging deeper into financial crisis as the public awaits the implementation of the minister's much-vaunted plan.
Before he resigned as HSE chief executive, Cathal Magee highlighted the risks involved in making big structural changes to the health system "at a time of very considerable reductions in funding and resources". At times of change, he said, governance and accountability were more important than ever.