To trust or not to trust?

Senior Irish health managers are urging that the Minister for Health, the Department of Health and the HSE should open a broad engagement with staff on how the new hospital and community Trusts are to be established and structured – or indeed if they are necessary at all, writes Maureen Browne.

Senior Irish health managers are urging that the Minister for Health, the Department of Health and the HSE should open a broad engagement with staff on how the new hospital and community Trusts are to be established and structured – or indeed if they are necessary at all.

Maureen Browne
Maureen Browne

They say that the current lack of any structures for discussion or debate are truly shocking and the “news” on the grapevine is that none is planned and that decisions will be taken by a couple of people at the top and then foisted on the system as a whole.

The first item which managers believe should be down for discussion is that, in the event of the establishment of Universal Health Insurance, whether it is necessary for Trusts to be established at all.

There is also the question as to whether hospitals would be allowed to buy services from major centres of excellence outside their Trust or if they would be required to pay for this, as has happened in the UK

“Those at the top of the Department and the HSE seem fixated with structures,” said one manager. “In fact, you could introduce UHI without setting up Trusts. I see no cogent argument for Trusts, especially as there is no indication that the Government will allow Trusts to determine pay and conditions. Basically under UHI, providers will be buying services regardless of corporate status and if a hospital wants to provide a service which requires rationalisation, it should be up to the hospitals concerned to make these arrangements.

“I see two issues involved. It would facilitate rationalisation of services in the so called “voluntary hospitals,” which are now either state owned or rely on the state for the majority of their funding. But rationalisation should be driven by policy and large Trusts could make it more difficult to deal with hospitals in relation to national planning. I could see a situation developing where powerful Trusts would try to develop new specialties and introduce new procedures and insurance companies would not be able to keep funding them. There is already a move toward co-payments and with those covered by health insurance set to shrink to about 35 per cent, I just wonder where this will leave those in the lower socio economic groups and where the State will  get the money to pay their premia.”

There are expected to be challenges in establishing Trusts which would include state owned hospitals, the voluntary hospitals, most of which are now limited companies and private hospitals

There is also the question as to whether hospitals would be allowed to buy services from major centres of excellence outside their Trust or if they would be required to pay for this, as has happened in the UK

In the West and the Mid West, some  people see the new hospital arrangements – which to a large extent have moved back towards the old health board model – as a move towards establishing Trusts in those areas, but at present they are basically just management arrangements, without any clarity regarding autonomy.

The fate of hospitals around the country, particularly the smaller hospitals, the possible rationalisation of their services, the breakup of networks and local loyalties are complex issues. There are very real fears that some existing integrated acute hospital networks may be chopped and pulled apart without any proper analysis of these issues. While it is freely admitted that all the networks are not perfect, they say it is being forgotten that they are operationally inter-dependent, have clinical governance links and joint consultant appointments.

There are expected to be challenges in establishing Trusts which would include state owned hospitals, the voluntary hospitals, most of which are now limited companies and private hospitals, whether Trusts should include a range of hospitals providing different services, whether specialist hospitals would group together in Trusts and if geography should be a determining factor in establishing Trusts.

There are very definite fears that smaller specialty hospitals could be “swallowed up” by Trusts dominated by large acute general hospitals. As one manger said “If you were to bring Dunlop and Ferrari together, there is really no reason why Ferrari should run Dunlop. We must also consider what size an organisation should be to be effectively managed. What is important is that we have uniformity and consistency and a level playing pitch. If we are to set up Trusts, it is also essential that we move to multi-annual funding.”

There are a number of possible configurations in Dublin. On the northern side of the city, discussions are well advanced on an amalgamation of services between Beaumont and Connolly Hospitals in conjunction with the establishment of an Academic Health Centre with RCSI. There is the possible addition of Our Lady of Lourdes Hospital in Drogheda. There are already close links between the Mater Hospital, the National Orthopaedic Hospital in Cappagh, St. Vincent’s Hospital in Fairview and the Children’s University Hospital in Temple Street and it seems very possible that these could link up under one management.  If the Mater Private Hospital also became part of this conglomerate, these hospitals could become either one or two large north side Trusts.

There are very real fears that some existing integrated acute hospital networks may be chopped and pulled apart without any proper analysis of the issues involved

However, under another scenario, the Children’s University Hospital in Temple Street could join up with Our Lady’s Hospital in Crumlin and the National Children’s Hospital in Tallaght.  Then, there is the Rotunda Hospital and whether this would fit in with a north side trust or become part of a trust covering all the maternity hospitals is up for debate as are the implications for the Dublin maternity hospitals with long established Charters.

On the south side of Dublin, St. James, the St. Vincent’s Group, Tallaght, the Royal Victoria Eye & Ear and St. Columcille’s Hospitals could form the base for one or two Trusts.

Another aspect of the jigsaw which must be taken into account is the establishment of the new Academic Medical Centres.

Beaumont and Connolly and possible Drogheda, are set to amalgamate their services in conjunction with the establishment of an Academic Health Centre with the RCSI. The Mater & the St. Vincent’s Group have already announced that they will soon become part of an Academic Medical Centre, with a single board of management in conjunction with UCD.  St. James’s and Tallaght Hospitals and the TCD School of Medicine are re-organising their services into an Academic Medical Centre.

These are all areas which need broad debate and engagement with staff and this is not being carried out at present.