15 years of chopping and changing of Health structures

Fifteen years ago next month the then minister for health and current Fianna Fáil leader Micheál Martin announced a major programme of health service reform which at its heart involved the abolition of regional health boards and the establishment of a centralised Health Service Executive (HSE).

The aim was to rationalise the 58 agencies then operating in the public health system and to put in place “standardisation and much improved co-ordination”.

Martin said that in a system as complex and broad in scope as the health service, it was obvious that clarity about roles, accountability and “where the bucks stops” must be completely clear.

Fast forward to May 2018 and the Cabinet on Tuesday considered proposed new legislation put forward by the current Minister for Health Simon Harris which seeks to "strengthen the management, governance and accountability" of the HSE.

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The new plan will seek to reconfigure the health service to include a more strategic “national centre” carrying out national-level functions, and with new regional bodies accountable for implementing integrated care.

Sources said Harris did not believe the existing structures provided an adequate governance arrangement for the HSE.

However, it is not just a case of the current Government 15 years down the line bringing the wheel somewhat full circle and heading back towards the way things used to be.

No clear path

The intervening years have seen constant chopping and changing of the structures with no clear consistent path being followed.

Martin oversaw the proposals to scrap the health board system and replace it with the centralised HSE while his successor Mary Harney implemented the plan.

This was facilitated by a deal with trade unions which ensured there was no rationalisation of staff. Health board employees could keep their jobs and their terms and conditions and there would be no forced relocation.

Five years later after austerity hit Harney announced a €400 million voluntary redundancy scheme which aimed to slim down staff numbers by up to 5,000.

At the heart of decision making in Harney’s HSE was a board appointed by the Minster which, unlike the former health boards, met and made its decisions affecting millions of people in private.

However, Harney's successor James Reilly was no fan of the HSE concept and on his arrival in the Department of Health was determined to get rid of the entire edifice. He wanted to move on to his own ambitious initiative to introduce a system of universal health insurance.

Under Reilly’s reforms the board of the HSE was abolished. The HSE was to be run by a directorate with directors responsible for specific areas such as hospitals, primary care, mental health, etc. At the top of the pyramid was to be a director general who would be handpicked by Reilly himself.

Reinstated

Responsibility for spending the multi-billion euro health budget was taken back from the HSE and reinstated in the Department of Health.

However, even these reforms were to be transitory. Reilly wanted the HSE itself to go by 2014 as the system of universal health insurance was put in place.

Under universal health insurance there was to be a new gamut of organisations established such as a healthcare commissioning agency, a healthcare pricing office, a patient safety agency, seven hospital trusts as well as primary and community trusts.

Ultimately the Department of Public Expenditure and Reform deeply wounded Reilly’s universal health insurance dream with arguments that it was unaffordable.

The project was ultimately killed off by Reilly successor in health Leo Varadkar, leaving the "transitory" HSE structure which Reilly created in place.

Under Harris’ new proposals the HSE board is to be re-established. Here we go again.

And with the new 10-year Sláintecare reform programme due to be implemented, further changes cannot be ruled out.