ANALYSIS:For nearly 20 years, every major health report has highlighted the need to clarify who is responsible for what in Irish health services, writes Sara Burke in the second part of her analysis of the HSE, writes Sara Burke.
WHEN MINISTER for Health Mary Harney was rushing health legislation through the Dáil in November 2004, she pledged to "retain clear accountability for our health services".
Last week she said no one person, including herself, is responsible for the "systemic failures" that led to the misdiagnosis of nine women in the Midland Regional Hospital at Portlaoise. The three Portlaoise reports hardly mention the Minister or the Department of Health apart from reference to poor communication with the HSE.
The 1989 Commission on Health Funding observed that "the simple question 'who is in charge' cannot be answered". Every significant health report since has specified the need to clarify who is responsible for what in Irish health services.
The establishment of the HSE on January 1st, 2005, was meant to resolve this for once and for all. However, the 2004 Health Act, which legislated for the foundation of the executive, did not specify the responsibilities of the department and the executive. There is no reference to the role of the department and its secretary general in the Act.
While the former health board system was widely criticised, most notably for political interference, some HSE staff and patients now look back on those days as more democratic and more accountable.
The health boards comprised public representatives, health professionals and political appointees. They held monthly board meetings open to the media and staff, where management had to answer questions. No such accountability exists in current structures.
The HSE board is appointed by and accountable to the Minister. There are no worker-directors. Meetings are held in private. There are no media or public representatives in attendance. Minutes of board meetings are on the HSE website but no detail of presentations or documents circulated are contained in the minutes, so they are virtually meaningless to anyone except those present.
New HSE structures such as a national forum and regional health forums are in place, but are considered by some as mere window dressing, far removed from decision-making arenas.
The HSE submits service and capital plans to the Minister who then lays them before the Houses of the Oireachtas, but the Minister is not directly responsible for them. The result of this is that the person in charge of HSE finances and services, Prof Brendan Drumm, is at arm's length from the Oireachtas and the people.
He, with the Minister, makes a quarterly appearance at the Oireachtas health committee. Last week's meeting involved the committee members asking questions for over three hours, with just minutes for each to respond.
Previous forms of accountability have also been weakened. Prior to the HSE, all parliamentary questions (PQs) on health went to, and were answered by, the Minister; responses were prepared by departmental officials. There was open debate on PQs in the Dáil with the Minister responding directly to questions and criticisms.
In 2005, regulations for dealing with Dáil questions were not in place so the majority of questions were unanswered. In 2006, 95 per cent of Dáil questions referred to the HSE remained unanswered. The executive now has a target of responding within 20 days and says that 75 per cent of PQs met the target in 2007.
Critical to accountability is money. Contrary to the advice from civil servants in the departments of health and finance, the role of the health accounting officer was handed over from the secretary general of the Department of Health to the chief executive of the HSE. Where the "accounting officer" is located is significant because in the words of one senior official in health: "Whoever holds the purse strings, holds the power."
Another official close to the negotiations at the time said "no one in the department ever really believed the Minister would hand over control of €11 billion to the HSE. Once she did, the department was left feeling emasculated".
In the weeks before the executive was set up in 2004, the Department of Finance was in regular correspondence with the Department of Health expressing concern over the ability of such a new organisation to manage such a large and complex budget.
On September 4th, 2007, the HSE management introduced overnight cutbacks to make up for a €200 million overspend in its budget.
Last December, Minister for Finance Brian Cowen wrote to Ms Harney expressing his serious concern about the overspend, declaring that it was "the latest indication that the HSE spending is not being efficiently managed".
The 2007 Report of the Comptroller and Auditor General also criticised the HSE for significant unsanctioned spending on PPARS, an integrated, computerised payroll system originally intended to work across the HSE, and subsequently abandoned.
A central motive for setting up the HSE was to bring together the 11 health boards, the voluntary hospitals and a raft of other health agencies under the management of one unified health service. While in theory the executive was announced in mid 2003, very little was worked out in the detail of roles and structures prior to its establishment in January 2005.
From the word go, there was confusion about where services fitted into the new structures, who reported to who and who made what decisions.
Three years later, many of the loudest complaints about the HSE are that there are many more layers of bureaucracy - that it's impossible to get a decision made, to know who reports to who, and who is responsible for what. According to Liam Doran of the Irish Nurses Organisation (INO), "it's worse than ever before".
Politicians, like Éamon Ó Cuív and Mary O'Rourke, have spoken publicly about the difficulty of findings one's way around the HSE.
While nationally and internationally, the trend is to decentralise public services, the HSE has centralised decision-making. Many middle and senior managers who lived and worked in the regions of the old health boards, now spend their time commuting to executive HQ in Naas and Dublin.
A further area for confusion and frustration within the HSE is the role of Mr Drumm's advisers. As part of his package, he brought with him six advisers. Staff at middle management and on frontline services believe that key decisions are made by Mr Drumm's "kitchen cabinet" rather than by the management team made up of the national directors.
"In the INO's experience, there is a genuine disconnect between Drumm and his immediate advisers, and the senior management grades", says Doran.
The other key policy development since the HSE came into existence is increased privatisation of health services. While there has always been a public/private mix in Irish healthcare, the announcement in July 2005 to co-locate private hospitals on the grounds of public hospitals firmly institutionalises for-profit care into public health policy.
Changing structures, particularly those as big as the HSE, takes time. Vincent Barton, director of Prospectus, who wrote the report that influenced the establishment of the HSE says: "This is long-haul work, on a larger scale than any other public service redesign programme in the State. International experience shows that changes of this sort take a number of years to bed down and can be hard to sustain in face of the more short-term pressures of political or fiscal cycles."
The Portlaoise debacle demonstrates that the initial aims of the HSE - a unified, accountable, quality health system - are not yet realised. Whether these are achievable, in the absence of clearer roles and responsibilities for the Department of Health and the HSE, without greater accountability within the executive remains to be seen.
Harney's pledge to retain clear accountability for the health services remains an unachieved goal.