Should the Department of Health and HSE be merged?

In a recent column in The Sunday Business Post, Tony O‘Brien, former Director General of the HSE, argued that the possibility of a merger of the Department of Health and the HSE should be on the healthcare reform agenda, writes Denis Doherty.

Denis Doherty
Denis Doherty

A merger and a market driven mindset would, he argued, “seek to remove unnecessary organisational confusion and the ambiguity it produces, and eliminate any cost that does not add value”.

Fair point, but even if it were to happen could it address the type of structural reform that would be required if a Sláintecare type of service model were to be implemented?

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In an earlier extensive interview published in The Sunday Business Post, O’Brien spoke of the disconnect between policies and promises on the one hand and what has been delivered on the other. Progress or the lack of it to date in implementing the recommendations in the Sláintecare report is such that I will be surprised if it is ever implemented.

The Sháintecare model is, in my view, a purer version of the NHS model in the UK, one that is closer to Bevan’s vision of the NHS than what is being delivered at present. A Sláintecare type system lends itself to being structured in the way the NHS is structured now: a policy entity (the Department), a procurement entity and a delivery network. It also lends itself to the type of market driven approach favoured by O’Brien.

The ambiguity in relation to policy that O’Brien is critical of could have been avoided by a more assertive approach by the Department from 2005 onwards in the fulfillment of its role in relation to policy, oversight and legislation. The inadequate approach to the allocation of resources could have been avoided by the HSE if it had prioritised, when it was established, the development of a transparent and equitable system of allocating resources.

Progress or the lack of it to date in implementing the recommendations in the Sláintecare report is such that I will be surprised if it is ever implemented.

Our health delivery system is bedeviled by what seems like a default mode of reverting to doing things the way we always did them. Remember the GUINNESS television advertisement featuring a pub being changed back to look how it used to look? The point of that was to convey the unchanging goodness of ‘the black stuff’.. Healthcare practices are changing rapidly but the approach to funding healthcare provision is not. Take the 2019 budget for example. Sláintecare is said to have all-party support but implementation of its recommendations is way behind the promised timeline. The allocation towards the implementation of the Sláintecare Report in the budget is a notional sum in the overall budget context; the bulk of the additional funds available were earmarked for the purpose of doing more of the same. Roy Keane’s definition of stupidity – doing the same things and expecting different results – springs to mind.

My fear is that a merger of the Department and the HSE would amount to little more than a return to the pre 2005 model of dominance by the Department and which, by common consent, was not fit for purpose. How resources were allocated was, at best, opaque, did not reward efficiency and value for money and indulged overspending.

A merger of the Department and the HSE would be unlikely to lead to a market driven, value focused system that would be responsive to the healthcare needs of the population.

If the purpose of a health department ought to be policy, legislation and oversight then the arrangements in some Scandinavian countries are worth looking at. They don’t involve legions of staff either.

The likelihood is that our delivery system will, for the foreseeable future, continue to rely on a mix of public, private, and voluntary providers. The market driven approach that O’Brien advocates will function best in an environment in which there is transparency and equity based on relevance, quality, quantity and cost.

Healthcare services are capable, it appears, of consuming infinite volumes of resources and are not good at demonstrating that available resources are being used to best effect. Demand for certain services often wins over services that are more needed. That creates dilemmas for those who determine what services are most needed and where they ought to be provided.

Cancer services are effective and efficient following reorganisation based on need and best practice. That should be the norm in resource allocation and service delivery but is patently not the case.

A merger of the Department and the HSE would be unlikely to lead to a market driven, value focused system that would be responsive to the healthcare needs of the population.

That is unlikely to improve until a resource allocation system is introduced that is based on stated polices, assessed need, high delivery standards, cost efficiency and clear accountability.

In governance terms and having regard to current and past practice, that function needs to be separate from the Department and service provider organisations. It ought to be staffed by a wide range of specialists in areas such as health economics, public health, accountancy and information technology.

Surely all providers of healthcare ought to be licensed and obliged to comply with the terms of their licenses at all times? If that were to happen, would we have any need for bureaucracies such as hospital groups, the proposed hospital trusts, community service organisations and so on?

Licensed providers might well wish to form representative organisations and indeed might even be encouraged to do so, as a means of creating worthwhile interfaces between those who commission and evaluate services and those who provide the services.

I share Tony O’Brien’s view that the future role of the Department of Health ought to be on the agenda of the debate on the future arrangements for healthcare here. The problem is there is not a debate taking place. What I judge to be the pretense that Sláintecare is the future is tantamount to sleepwalking into a growing healthcare crisis. In his interview in the Sunday Business Post, Tony O’Brien offers perceptive insights into much that is wrong with our healthcare system. Sadly some of the issues he raised were covered in the Fitzgerald Report of 1968. I am encouraged that someone of O’Brien’s experience and keen interest is engaging in public discourse on how public healthcare can be improved.