Friday 22 November 2019

Maurice Hayes: Reilly has taken out the HSE's brain but left its carcass

There is no advantage in having a medical doctor, like Dr James Reilly, as Minister for
Health, writes Maurice Hayes.
There is no advantage in having a medical doctor, like Dr James Reilly, as Minister for Health, writes Maurice Hayes.

DR James Reilly, newly come to the Department of Health, has implemented his pre-election promise to get rid of the Health Service Executive in the most dramatic way possible -- by publicly performed brain surgery.

In the most invasive way possible, with a minimum of anaesthetic, he has removed the board (or induced it to make itself scarce), leaving, however, the vast bureaucratic carcass of the leviathan beached somewhere in the department.

At first sight, even before they were so fulsomely lauded by the minister, the personnel on the board seemed to be the sort of people the Government had professed to wish to involve in the corporate governance of the public sector.

The problem in the HSE was not principally the board but the bureaucracy -- and the board's apparent inability to deal with it.

Removing the brain and leaving the carcass does little to solve the problem.

Neither does the minister's proposed solution of a brain implant supplied by senior staff in the department and the HSE hold promise of a rapid return to health.

Departments of health (and I spent much of my working life in one) are not very good at managing the delivery of health services, and the people in the HSE have already demonstrated a systemic inability to do so.

A basic problem with the HSE is that there are simply too many people trying to do the same job -- a direct result of the failure to shed staff when all the health boards were amalgamated into a single entity. The result, too, has been chronic inefficiency arising from over-manning, lack of clarity in lines of responsibility and poor internal communications.

It is hard to see how this will change within the ringfence of the Croke Park Agreement and the mantras of no compulsory redundancy (voluntary redundancy too costs money) and no cuts in public-sector pay.

Neither is anyone asking the fundamental question of why so much of the five-fold increase in health spending over the last decade and a half was devoted to improving pay and conditions for those working in the service and so little, proportionately, to improving conditions and outcomes for patients.

There is no inherent advantage in having a medical doctor as Minister of Health. The job of the minister is to provide political leadership and accountability rather than technical competence. It cannot be assumed that any one doctor can bring a consensus view shared by all sections of that profession, not to mind other professions and groups involved in the delivery of services.

Dr Reilly does have the advantage of having had a period as shadow minister and of having developed policies in opposition.

Whether they are the right policies remains to be seen. He should be aware of the danger of consuming too much energy and too many resources on structural change at the expense of changing the culture and maintaining services for patients.

The emphasis on developing universal primary care free at point of delivery is surely the way to go, and will also have the effect of reducing pressure on the hospital sector -- for which the Hanley report is still on the shelf for any minister with the courage to take it down and a government with the political bottle to carry it through.

It may not be so easy simply to take the Dutch system of universal health insurance and graft it on to the Irish root-stock, given the differences in political culture and medical practice.

One is reminded of a wicked remark by a cynical English politician in the 19th Century that the way to solve two European problems was a population transfer between Ireland and Holland. The Dutch would transform Ireland into a garden of flowers, and the Irish, fighting among themselves, would neglect the dykes and be inundated.

At some stage, too, Dr Reilly must feel like Frankenstein, confronted by the monster which, in a previous incarnation, he helped to produce -- the very generous pay and conditions of the medical profession and the comparative luxury (and managerial impossibility) of the consultants' contract, with its lethal mix of public and private practice.

The reorganisation of primary care in the lifetime of a government, as well as getting a grip on waiting times for critical hospital treatments, would be a very considerable achievement for the minister -- more than enough to be getting on with.

Paradoxically, the rush to bring management of the health service in house to the department sits oddly with the pre-election promises to involve outsiders more widely in public administration.

More widely, too, the search for scapegoats for the crisis in the public finances has tended towards a simplistic polarisation in which the civil service is portrayed as the weak link.

However, both the Nyborg report and Pat Leahy's riveting account of Fianna Fail-led governments make clear the extent to which the civil servants were sidelined and their advice ignored.

In this context, the view is essentially short-term, dominated by the electoral cycle and the dynamics of spin, lacking the longer-term strategic view which should be provided by departmental civil servants -- not a great recipe for taking tough and politically unpopular decisions about local services.

One can only wish Dr Reilly well.

Irish Independent

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