Blueprint for the future critical for new health service, says Minister for Public Expenditure
TENSIONS BETWEEN Ministers who hold the Exchequer’s purse strings and Ministers for Health are nothing new. Certainly Charlie McCreevy and Micheál Martin had their moments even in relatively good financial times in the early 2000s.
With the HSE facing a potential €500 million deficit, it was probably to be expected that Minister for Public Expenditure Brendan Howlin would intervene directly with Minister for Health James Reilly on the issue – although the phraseology used, which requested Dr Reilly become “engaged personally” in dealing with the problem, was stark.
Moreover, other official correspondence shows Mr Howlin’s worries do not centre exclusively on the HSE’s deteriorating financial position.
He is also concerned at elements of Dr Reilly’s overall reform plans for the health service and wants to ensure clear governance structures are put in place and there is no repeat of the overmanning and the appointment of large numbers of senior managers which accompanied the establishment of the HSE several years ago.
Mr Howlin told Dr Reilly of concerns about the financial governance, industrial relations and human resources issues that would inevitably arise in putting in place the Government’s commitments on health reform. He said reforms “should be implemented in a way that is consistent with wider programme [for government] commitments in relation to national recovery, public service reform including estimates and performance management, and with Government pay and employment policies”.
In focusing on reform, he said, it would be important “that we do not lose sight of the overarching national fiscal consolidation targets and the imperative of delivering better quality services within Government-approved resources”.
He said sound governance arrangements should be put in place and clear lines of decision making that reflected the separation of functional responsibilities between policy and operational matters, and the roles of accounting officer and regulator, both in the transition phase and under the health structures envisaged ultimately in the programme for government.
It was critical the Department of Health produced a map or blueprint for the future, he said. This should set out clearly the functions of existing health service bodies and what these will be, both in the transition phase and in the final structures. The blueprint should also set out the details of new bodies to be established as well as any new additional functions.
This blueprint should also set out governance arrangements for each existing body and its relationship to other health organisations and on how these would evolve in the transitional and final stages of the reforms. This should indicate who at each stage would be responsible for policy and for operational matters, and the roles of the accounting officer and regulator for the bodies concerned.
The plan should spell out who was currently responsible for decision making and who would be responsible for this in each body in transitioning from the current system to the proposed new models under the reforms.
“This should indicate the structure and decision-making responsibilities of the CEO, national directors and assistant national directors and clinical managers within each body and for corresponding bodies under the transitional and final stages of reform. It should also make clear what positions will be retained or suppressed and replaced under each phase of the process.
Mr Howlin warned that unless such a blueprint was produced upfront, it would be impossible to judge or assess the effectiveness of the new governance arrangements.
“In its absence, there would be a real danger of confusion occurring within and across bodies in relation to ongoing operational management and management of the reform process itself. There would also be the risk of increased cost and upward employment and grade drift, as occurred when the HSE was being established.”
The quality and effectiveness of the HSE’s existing management systems were of concern, according to Mr Howlin. “Its systems, and the systems in the sector as a whole, are unable to tell us in real time who at an organisational level is spending what cash and what we are getting at care-programme level or at an organisational or individual patient level for that cash spend.
“Accordingly I consider the introduction of a national financial management and procurement system, changes to the HSE’s business coding system and restructuring of its vote along care programme lines consistent with its service plan to be an equally high priority.”
The proposed establishment of new agencies and separate hospital insurance and primary care funds as well as new principles such as individualised budgeting made it more imperative that there were common management and ICT systems in place across the different areas of the health service, according to Mr Howlin.
He stressed that contract talks with hospital consultants and GPs should be completed as a priority. He urged all barriers in the current GP contract should be removed to reduce the unit cost of medical and GP-only cards so as to allow the phased roll-out of universal GP access within available resources.
He also recommended a more ambitious approach to the Croke Park agreement to seek more flexible working practices and changed skill mixes, and urged that a coherent overview of the issue of eligibility for services be undertaken.
