Using our money more appropriately and more effectively

We all have a vested interest in Tony O’Brien succeeding; our health service is urgently in need of major reform and if he is successful in achieving improvements we will all benefit. I wish him well; it isn’t going to be easy, writes Denis Doherty.

Who would envy Tony O’Brien the task he has taken on? The three former holders of the position of CEO of the HSE – Kevin Kelly, Brendan Drumm and Cathal Magee – worked hard but didn’t attract much appreciation of their efforts. We all have a vested interest in Tony O’Brien succeeding; our health service is urgently in need of major reform and if he is successful in achieving improvements we will all benefit. I wish him well; it isn’t going to be easy.

Denis Doherty
Denis Doherty

During the last week of August he announced service cuts and in the days and weeks that followed it seemed like health service issues dominated the news. What appeared to be a concerted anti Croke Park Agreement campaign took up a great deal of time and space. The Minister for Public Expenditure and Reform, Brendan Howlin, was quoted as saying he would be supportive of the Minister for Health, Dr. Reilly, “in ensuring health service managers take responsibility for meeting their budgetary targets through proper and careful management of their staffing and resources”. That suggests that managers have the authority and the discretion needed to achieve budgetary targets; the reality is they do not have either the authority or the discretion required.

Professor Ray Kinsella took the view that budget plans to reduce spending on care for ordinary people arise from a systemic failure to see the value of investing in health and wellbeing

In fairness, the Minister used the term ‘budgetary targets’, thereby acknowledging that the targets may not be achievable. In a reflective and well-argued opinion piece, in the Irish Times on September 4, Professor Ray Kinsella took the view that budget plans to reduce spending on care for ordinary people arise from a systemic failure to see the value of investing in health and wellbeing. He claimed that budgetary slippage in healthcare in 2012 was inevitable from the outset because the service is underfunded relative to what it is expected to deliver. He claimed, “The limits of ‘doing more with less’ and similar management-speak platitudes within the system as it stands have been well and truly reached”. The reaction of the public and the media to the announced cut in the budget for personal assistants for people with disabilities suggests that public opinion favours the type investment in health and wellbeing that Professor Kinsella advocated.

Of course, investment in healthcare ought to be carefully planned and well targeted. The amount available for investment will continue to decline as the government seeks to achieve a closer balance between what we spend and what we raise through taxes. Reductions in pay costs in the public sector have been achieved and perhaps more is needed. Not nearly enough has been done though to develop more appropriate, more effective and more efficient ways of using the money available for healthcare.

New procedures and technologies tend to attract more interest and commitment than new ways of organising and delivering services

It is generally agreed that primary care ought to be at the centre of how healthcare is organised and delivered. Progress has been slow in putting in place the facilities and the staff to deliver a modern primary care service. It is generally agreed also that care at home is preferable to care in an institution. Home help services, home care packages, personal assistant numbers and support of home- carers need to be expanded, not cut.  Modern, community based, mental health and social services need to provided in all areas. It follows that our traditional reliance on institutional care for older people, those with mental illnesses and disabilities and especially for the diagnosis and treatment of acute illnesses needs to change quickly.

Efficient business practice would demand that diagnostic facilities be dispersed and be accessible to all relevant health professionals, that treatment be delivered where it is most cost effective, appropriate and convenient;  that acute care be organised and delivered in ways that are most effective and efficient and that residential care be planned, organised and delivered to meet needs that are best met in a residential care setting. That type of approach is certainly not new, so why is it taking so long to see real change happening? The reasons are many and varied. Health services, hospitals especially, are slow to change. We have tended to rely on new money to do new things or to do things differently. Services tend to be organised and operate in stand-alone silos. New procedures and technologies tend to attract more interest and commitment than new ways of organising and delivering services. We have not invested in the people and the skills needed to lead and deliver sustainable change in what is a large and complex system.

The experience of recent years and the prospects for the coming years suggests that we should, at last, rise to the challenge and do, as a matter of urgency, what ought to have been done years ago. We should invest in health and wellbeing, using the best approach we can devise, based on the amount of money we can afford. We should aim to achieve the best return on our investment in the form of benefits to the health and wellbeing of the people of this State.