Health Minister, Simon Harris wants to dismantle the HSE and replace it with a much leaner national agency, with services provided locally by a number of regional delivery units based on geographically aligned Hospital Groups and Community Health Organisations. Maureen Browne reports.
These new regional units would be established on a statutory basis to deliver integrated care within defined geographic areas, the Minister told the Oireachtas Health Committee, which is to make recommendations shortly on a long-term vision for health care and the future direction of health policy in Ireland.
Mr. Harris also raised the possibility that the Department of Health could take over the commissioning role in a reorganised service.
Laying out his own perspective for the future of health care in Ireland in a wide ranging presentation, he said he wanted to tackle health inequality and improve access for people to health and social care.
He wanted to increase health service capacity and staff and shift our system from hospital-centric care to more comprehensive and accessible primary care and community care, with a greater emphasis on continuous rather than episodic care.
The Minister said it would make sense to remove any incentives for public hospitals to treat more private patients.
I intend to ask my Department to come forward with proposals to improve governance arrangements for the HSE for so long as the HSE continues in its current form.
This would involve private patients in public hospitals paying a similar fee to that paid by the HSE for public patients, under Activity Based Funding.
It would also involve the abolition of fees by private patients to consultants in public hospitals and the introduction of a new consultants’ contract under which consultants would receive a salary to cover their public and permitted private work in their public hospital.
While the Minister did not give specific timeframes for these re-organisations, he would appear to be considering a ten year timeframe.
“He said that in deference to the Committee’s work, he had not moved ahead to date with structural change or changes in HSE governance.
“I am not a believer in structural change just for the sake of it and it has not proved a panacea in the past. However, if our structures are not best serving patients, then change they must.”
Mr. Harris said the national health capability to take the place of the HSE when the new regional units were placed on a statutory basis was likely to be a slimmed down body; “one more equipped to lead than to directly control and, accordingly, with less management layers between the top and the front line.”
He said he intended to ask the Department of Health to come forward with proposals to improve governance arrangements for the HSE for so long as the HSE continued in its current form. “This will include examination of the current vesting of governing authority in the HSE Directorate, including the fact that the Director General is responsible to the Directorate for the performance of his or her functions.”
“I must stress that when I talk about HSE structures not serving patients or others in need of services I am not talking about HSE staff. In fact, staff are also impacted negatively by structures which are in place.”
We need to retain such capability and avoid reverting to stand-alone geographically based organisations in the mould of the health boards.
While Ireland had added over five and a half years to life expectancy over the last two decades alone due to progress on major causes such as cardiovascular disease and cancer, there was concern over the performance of the health system, the outcomes achieved and the economic sustainability of the sector. Compared to many other countries, Ireland had a relatively high percentage of the population who reported having unmet need and the main reason for this was the cost of health care.
The Minister said that the overall HSE project initiated in 2005 could be legitimately criticised in a number of areas, but the need for national arrangements for planning and sharing of expertise and services for a population of less than five million people could not be criticised.
Many of the statutory responsibilities of the HSE could be transferred to Hospital Group and CHO level, but others demanded a national body for their proper discharge. “We have gained much in recent years through national initiatives in areas such as the cancer programme, the integrated care programmes, the Fair Deal scheme, eHealth and many other areas. We need to retain such capability and avoid reverting to stand-alone geographically based organisations in the mould of the health boards.”
Mr. Harris said there was also a question as to the respective roles of such a body and the Department of Health. “In some countries of not dissimilar size, such as Scotland, the Department itself commissions services from regional providers, but in others an organisation at a remove from Government and the civil service plays this role nationally.
The new regional units would bring decision making closer to the point of care delivery and provide a counter-weight to the over-centralisation of decision making and accountability which impeded service responsiveness, he said.
Due to considerations of specialism and critical mass, hospital services generally required to be organised across larger populations than community services but a Hospital Group should ideally cover the same geographic area as one or more CHO.
“The challenge in any set of proposals is to devise a clear set of principles and a framework of accountability which ensures better and more rapid decision-making and responsiveness, but which also fully recognises the demands of parliamentary accountability.”
The Minister said that we needed to consider the challenges to the development of more comprehensive and integrated primary care.
“It has not always been easy to combine the efforts of salaried HSE staff and GPs paid through capitation for medical card holders and fee per visit for others. Coverage and eligibility have also been issues. For example, how can the role of primary care in population health, disease management and hospital avoidance be fully realised when the State’s financial support is predominantly concentrated on paying for access for the one-third of the population with the lowest incomes?
“Also in introducing improved primary care facilities we now have examples of very successful Primary Care Centres, but we have faced problems in some areas with GPs locating in such centres.”
The Minister said the key priorities he believed needed to underpin the future direction of the health service were:
- Shift our model of care towards more comprehensive and accessible primary care.
- Increase health service capacity, in the form of physical infrastructure and staffing, to address unmet need and future demographic requirements.
- Exploit the full potential of integrated care programmes and eHealth to achieve service integration around the needs of patients across primary, community and acute care.
- Strengthen incentives for providers to effectively respond to unmet health care needs by ramping up Activity Based Funding.
- Empower the voice of the clinician and provide them with opportunities to contribute to the management of our health services.
- Further develop Hospital Groups and Community Health Organisations, align them geographically and, as they develop, devolve greater decision-making and accountability.
- Follow this with the provision of a statutory basis for Hospital and Community Health Organisations, operating as integrated delivery systems within defined geographic areas.
- Once statutory responsibilities and accountabilities are devolved from the centre to Hospital and Community Health Organisations, dismantle the HSE and replace it with a much leaner national health agency. In the interim, reform the existing legislation within which the HSE operates to improve governance.