Saturday 17 August 2019

Patricia Casey: 'Moving deckchairs didn't save the Titanic, and won't do a thing for our health service'

Minister: Simon Harris will oversee the newly re-established HSE board. Photo: Collins
Minister: Simon Harris will oversee the newly re-established HSE board. Photo: Collins

Patricia Casey

Cabinet has agreed proposals to make changes to the HSE, following the Implementation Strategy which was developed by the cross-party Oireachtas Committee on Healthcare.

In 2017, Sláintecare, the committee's blueprint for the 10-year strategy, was published. It found "fundamental and deep-rooted problems" in our current healthcare system despite the commitment of various governments to deal with them over decades.

There are four broad strategic goals set out in the Sláintecare document - improved and strong governance, high quality accessible and safe care, ensuring that this is financially sustainable, and enabling the system to deliver the promise. Within each of these, specific changes are to be implemented.

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These are numerous and include the re-establishment of the HSE board, which was abolished in 2011 when James Reilly was health minister.

The chief executive will be appointed by, and will be responsible to, the board for his or her actions and it in turn will report to the health minister.

There is to be alignment between hospital and community health groups.

Specific commitment to increasing the mental health budget is mentioned, with €55m added to psychiatric funding for 2019. This unfortunately represents only a 0.15pc increase in funding relative to the total budget. So it is a pittance.

A new Healthy Ireland fund (whatever that means) will be created. A third group of initiatives includes removal of private practice from public hospitals and the provision of three new hospitals in major cities, while the fourth category involves expansion in GP training places, the recruitment of an additional 942 nurses and midwives and eHealth investment.

The initiative that is the most striking, and that has received most attention, is the establishment of six new regional health areas with each in charge of its own budget. This is apparently to ensure better accountability.

What is remarkable is that this is a management restructuring rather than a root and branch change. This reshuffling is reminiscent of the past.

A quick walk through time is instructive. Prior to 1973, health care was delivered by the county councils and various hospitals such as county hospitals, voluntary hospitals and so forth.

After the enactment of the 1973 Health Act, eight Health Boards were established and these morphed into slightly changed versions with seven Health Boards and, in Dublin, four of what were called Regional Health Authorities. Thus, there were 11 entities nationally overseeing healthcare delivery.

In 2005, these were replaced by the Health Service Executive (HSE) on the basis of four regions and in 2013 these were changed to six hospital groups (linked to the universities) and nine community healthcare organisations.

Now, examining the new departure announced earlier this week it's tempting to think 'plus ca change, plus c'est la meme chose'.

A continuing problem is that agencies like Blood Transfusion Service, the Central Remedial Clinic, Cervical Check and Breast Check, are still not part of the HSE but are contracted by that organisation to deliver specific services and the HSE has little governance over them.

The announcement earlier this week does not deal with this issue, even though the CervicalCheck fiasco was one of the driving forces behind the need for this administrative change.

A further problem with Sláintecare is that the focus is on prevention and on developing community services, a mantra for healthcare officials for decades. For a young population, prevention is an admirable goal. For an ageing population like ours, it may be impossible because of the march of biology. Serious disease is intimately linked to increasing age.

Added to the increasing longevity of our population is the massive expansion in our population from three million in 1990 to 4.7 million in 2016 - a 50pc rise without a similar expansion of in-patient beds.

Many immigrants come from poorer economies and are more vulnerable to illness. Inevitably, supply outstrips demand resulting in trolleys in corridors, prolonged waiting lists and long delays in the emergency departments.

It is striking that the minister has chosen the historic approach of management restructuring rather than changing service provision from the bottom up.

No alteration in the number of managers will increase the consultant, nursing or bed numbers. Prevention, community care, transparency, accountability, and similar buzzwords won't alter the reality that there are more people, they are older and likely more vulnerable to disease.

Ireland has one of the lowest ratio of nurses and doctors to population numbers in the EU countries.

In psychiatry, we have half the number of consultants per head of population and half the number of psychiatric beds compared to the EU average. We are the third lowest overall. And our recruitment and retention problems are sinking in the quicksands of emigration.

We are bereft of doctors as more than 50pc of recently qualified doctors move abroad. The recent nursing recruitment drive has been an abysmal failure and is now shelved.

The deckchair moving on the top deck didn't save the Titanic and it won't save our forlorn health service. Let's start and build a sensible infrastructure, and the top layer can then humbly follow.

Irish Independent

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