First Published in The Irish Medical News May 6-2011-Ray Kinsella
The decision of the Health Minister James Reilly to dismantle the HSE and to replace it with a wholly different approach to the delivery of healthcare was signalled well before the general election. The replacement of the Board of the HSE , which it should be said had real strengths but was required to function in a dysfunctional model, was primarily about making a break with the past. The Minister’s decision will give real visibility to the new institutional and policy architecture. It will concentrate minds. The key issue is what difference it will make in delivering on those core values that have been trumpeted in successive “institutional reforms” over the last three decades: Fairness, access, quality of care, and a participative culture at the heart of which is the “person” in all of their needs. One might also add the development of the enormous research capabilities which are latent within our healthcare facilities. The “building blocks” of the new model are potentially transformational:
• Universal healthcare;
• A greater emphasis on diagnosis and care within a primary care setting and in the community;
• Funding arrangements that, in effect, follow the patient rather than being carved up among different peers and which must then accommodate to the rationing that is now endemic within the system.
Within this new architecture, the aim is to ensure greater autonomy for hospitals. This makes enormous sense in terms of incentivising not just best practice, but also a transformational change and with no dead hand of bureaucracy looking over their shoulder. At the same time, it is proposed to reorganise hospitals into trusts along the lines of the UK.
This should help to generate economies of scale, as well as of scope: that is, financial savings together with synergies in terms of activities and outcomes. In truth, there is little to be said of the present system as it developed. It is only fair to say that it didn’t start out that way. Whatever the intentions, a culture of control seeped in and caused systemic and terminal damage – notwithstanding the efforts of those within the system (and also, it should be said, of individuals within the HSE ) to make an increasingly fragmented, under-funded and unfair system operational.
In recent years, it has had to absorb “cuts” that were short-term, wholly counter-productive, and which have left a legacy reflected in, for example, the exigencies which have been resorted to in staffing arrangements that impact safety as well as the provision of services – and, worst of all, do so in a manner that was not immediately apparent. But staff know and the patient experience is increasingly corroded by the ‘smoke and mirrors’ that invariably characterise dysfunctionality. But it would be wrong to benchmark the new model against what is there.
It is, in principle, a wholly different approach. Attention will now focus on the nature of the universal care model; whether it should be compulsory, and the extent of coverage. It is worth pointing out that “point in time” comparisons with analogous models in EU and OECD countries can be misleading. There are also pressing challenges in integrating Ireland’s fraught, and increasingly unaffordable private health insurance system. These reflect significant regulatory and policy challenges that stretch back to the early 1990s and the third non-life insurance directive, which has never been fully implemented in Ireland. At the same time, these challenges should not detract from the fact that there is widespread popular support for setting a course for a universal healthcare system – the case which I argued for in these pages more than a decade ago.
The economic environment in which the Minister is operating is the most difficult and constrained in modern Irish history. Misconceived economic policies, reinforced by the terms of the EU/IMF “bailout”, and reflecting the interests of the large Euro zone core countries, have had a devastating effect on the public finances and on Ireland’s self-confidence and standing. They have also impacted on the lives of individuals and families and increasingly, on their health status. The reality is that, for reasons spelled out elsewhere, it is not going to get any better for as long as Ireland remains in the Euro zone under the hegemony of an orthodoxy which does not reflect the founding ideals behind European cooperation and which has confined Ireland to “cold storage”. That makes it all the more important to look for positives in the circumstances in which Ireland is now mired.............Read Full Article