Sunday 18 August 2019

Conor Skehan: 'Are we nearer to an answer on delivering our health services?'

Devolving health care is a difficult business, which can only work properly if regions converge and not diverge

'Integrated care demands integrated structure.' (stock image)
'Integrated care demands integrated structure.' (stock image)

Conor Skehan

The Department of Health's proposal to introduce new regions for the delivery of health services is to be welcomed. Any development is an improvement when it proposes moving the delivery of public services from the centre to places that are closer to people's homes.

Many Irish people remain blissfully ignorant of how unusual our system of governance is. Ireland is one of the most centralised systems of administration of any country in the EU - including the former communist countries of eastern Europe. Around 94pc of all tax is raised, controlled and spent by central government in Ireland - this is not normal, effective or efficient.

Normal countries have three distinctive layers of government. Local government delivers services to citizens - the range of services vary from country to country, but usually include basic planning, housing, transport, health, education, policing, waste and water. Regional government delivers a higher level of coordination of these services to ensure efficient delivery of large-scale infrastructure - especially for energy, public transport, major roads and water supply. Regions are also responsible for the allocation of specialisations such as higher education, institutions and health. Normal national governments concern themselves solely with international affairs, legislation the coordination of policies and objectives.

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Ireland needs to devolve powers to regions and local authorities. Minister Harris's announcement of transfer of powers to regions is a welcome start. There are, of course, many ways to subdivide a nation into regions - none is perfect - each serves different needs. So, for instance, people who care for the environment or fisheries use river basins to define regions while those involved in education, tourism or policing use variations on traditional provinces and counties; professional planners divide the country into just three large regions. All are compromised to meet the specialist needs of the end users.

Health planning is tricky. Ireland has learned, the hard way, that for specialisation it really is true that ''big is beautiful''. Big specialist hospitals are an absolute necessity to provide the volume of scale that facilitates the development of vital specialist experience for individual clinicians as well as providing the old-fashioned ''economies of scale'' that are needed to justify the cost of installing and running extremely expensive advanced medical equipment.

For this reason, a country of Ireland's size will only ever end up with one dedicated hospital for each of the big areas of medical specialisation. That hospital will need to be located as close as possible to the biggest concentration of citizens and Leinster is home to more than 55pc of Ireland's population - so this is where these big places will have to go. No argument there. We have tried to have local specialisations and it didn't work - people died.

But - and it is a very, very big ''but'' - most people, most of the time are lucky enough not have to deal with the major illnesses that need these big hospitals. Most people, most of the time need regular ongoing modern health care - which is increasingly about health care through regular prevention and early, ongoing treatment. This effort recognised that wellness involves integration with a wide range of services from home nurses, to clinics and social services. These are eminently suitable to a model that brings services as close to people's homes as possible. The provision of these close to where people live is, rightly, the main focus of the HSE's regionalisation initiative and it is bound to be an improvement.

However, the intention and execution of regional devolution are two very different things. The map of the proposed health regions appears to be a remarkably ''forced'' plan that results in the Dublin region [and Dublin city itself] being divided between three regions. An even more ''forced'' issue appears to be that the ''Major Hospitals'' that serve places as distant as Dungarvan, Belturbet and Athlone are all located in Dublin city. No doubt there are good clinical reasons - but when viewed through the lens of conventional administration and planning it all looks a bit forced. It certainly seems at odds with the laudable aim of ''moving functions from the centre to places that are as close to people's homes as possible''.

Integrated care demands integrated structure. Hospitals - especially big specialist hospitals - are an integral part of big cities. They do not exist in isolation from universities and specialist suppliers of staff, equipment and materials. Even more importantly hospitals are integrated with other public service providers that range from education to community healthcare, social welfare and An Garda Siochana (arguably our largest unthanked provider of real social services)

Will Dublin's community care workers, social workers and gardai all now need three sets of files and managers to interface with three different health authorities in one city? Hospital admission can be a chaotic business - there is no guarantee that an emergency hospital admission will occur within the same part of the city where the patient is resident.

How will a city region divided into three separate health regions ensure that patients in hospitals are overseen by one management structure without potentially coming under a different management organisation once they returned home [perhaps to stay for a while with a family member in a different part of the city] and need social or community services?

Every other type of regional plan appears to have found a way to accommodate the fact that the majority of the nation's population are concentrated in one area. Most places in the world recognise a ''Metropolitan'' region - but perhaps the Irish health service really is different to everything else, everywhere else.

Devolution of functions and authority needs to happen throughout all aspects of Irish public service. The HSE and the Department are to be commended for making a start in addressing this difficult issue, but it's only a start - there is still a long way to go.

Two further requirements remain. The first is to ensure that all regional authorities should aim to use the same regions as other public service providers wherever possible - to ensure integration and effectiveness. Perhaps there is a role for our new Office of the Planning Regulator in advising on the boundaries of new public service regions? The second, in the case of the HSE, is to ensure that the ''shape'' of regions matches the lives of the citizens that they are meant to serve. It will take a lot of convincing to justify how this is achieved by making three parts of the daily lives of Ireland's largest centre of population.

Regions must gradually converge - not diverge. Devolution is not about transferring the location of power. Devolution is about changing how power is transferred

Every step of planning how, and where, public services are delivered needs to be guided by the rule ''Near To, or Further From?''

Nearer to, or further from, integrated provision of devolved social services?

Nearer to, or further from, local service provision?

These are early days. It is hard to tell if this good idea will really be another step ''Nearer to''.

Time will tell.

Conor Skehan lectures about causes and effects of development in rural and urban areas at Technological University Dublin

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