We need two major care divisions — not a return to the health boards

By Fergus Finlay

Tuesday, July 08, 2008

IF YOU want to see where the HSE gets its money from, it’s all there in the book of estimates. You can find it easily enough on the web — just click on www.finance.gov.ie, and look under ‘Financial and Economic Information’.

In the wink of an eye you should be able to download the entire book of estimates and there is all the information you need about the HSE, from page 189 to 196. Loads of big figures, as you’d expect, and all the transparency in the world.

Or is there? In fact, if you turn to the next page, 197, you’ll find an appendix. I’ve been looking at books of estimates for 25 years now and I’ve never seen an appendix like this one before.

It’s headed ‘Revised Vote Structure for HSE’ and it has this note on top of the page: "In order to improve accountability and transparency in the Health Service Executive in regard to the use of voted moneys, a new vote structure along the following lines will be introduced… as soon as possible. The new vote structure is designed primarily to ensure that current expenditure will be counted for on the basis of the service programmes in the HSE’s service plan rather than on a regional basis as at present. The HSE will be required as a matter of priority to make the necessary changes to their financial management systems to enable vote accounting to be introduced on this basis."

That might sound a bit dull, but behind that little note there is a fascinating story. The first thing it reveals is that the Department of Finance believes the HSE isn’t transparent enough in accounting for how it spends its money. If you know the Department of Finance at all, that revelation is enough to make you sit bolt upright.

I worked for a government in the mid-’90s that introduced the Freedom of Information Act.

The original bill, which was designed by Eithne Fitzgerald, was fought tooth and nail by the Department of Finance which believed at the time the words transparency and good government simply couldn’t coexist in the same sentence. (And of course the moment Charlie McCreevy became finance minister, his department set about weakening the bill).

So it’s hard to see the Department of Finance as a campaigner for more transparency.

When you see them insisting that the HSE will be obliged in future to account for its operations on a programme basis rather than on a regional basis, you know something must be very wrong.

It’s easy enough to see why when you turn back to the earlier pages. The HSE will spend a little under 15 billion this year, but it has nearly 3bn in income from health levies and other sources, so its net estimate is just over 12bn.

And in the book of estimates, a little more than 9bn of that is accounted for by allocations to the eight regions within the HSE.

The greater Dublin area — HSE East — gets the lion’s share, of course, and HSE Midlands gets the smallest amount.

But the point being made by the Department of Finance is that the HSE was established as a single national entity. The Health Act 2004, which set it up, says on page 1 the purpose of the act is to establish the HSE and abolish the health boards.

So why, four years later, is the funding still being allocated as if the health boards still exist?

And why, four years later, is it still not possible to be precise about how the HSE spends its allocation, as opposed to where? The book of estimates does give some gross totals about how money is spent under a variety of headings (care of the elderly,

hospitals, primary care and so on), but in terms of public policy and the HSE’s ability to respond to changing needs, the way in which money is accounted for leaves a lot to be desired.

That, in any event, is the view of the Department of Finance — and that’s why, in appendix four, it has devised the way in which it wants the HSE to account in future, by programme rather than by region.

That way, we will all know in advance how much is allocated for, say, disability services or cancer care, and we will all be able to track whether or not programme targets are being met.

In addition, the HSE would finally become the single national entity it was meant to be, with all the flexibility and economies of scale originally envisaged.

Except none of that is going to happen now, is it?

Last week both the HSE and the Department of Health confirmed newspaper stories that the HSE is effectively to be broken up again, back into the regions that were abolished in 2004.

No one will admit that’s what’s happening, of course, but it seems clear that in this battle, unusually, the Department of Finance lost.

Who won? I’m not sure. I happen to think Brendan Drumm and others in the leadership of the HSE probably fought for a continuation of the single national entity, but in the end of the day there are so many powerful vested interests at play that this outcome was inevitable. According to the newspapers, a new devolved structure will be created under which regional directors will be given power to deliver an integrated healthcare service in their area.

The new regional directors will also be given authority for the healthcare budget in their locality and they will decide on how the money should be divided up between hospital, primary care, mental health and other sectors.

There is nothing new about that — it is precisely the system that the Health Act of 2004 set out to abolish.

Under the new plans, the Department of Health and the HSE at national level will become policymakers and standard-setters. That was the role of the department alone in the past.

WHATEVER about who won or lost the internal battles, what matters, of course, is that patients, and all the other people served by the HSE, emerge as winners.

In my opinion, if that’s what they wanted to achieve, the powers-that-be have gone the wrong way about it.

Instead of splitting the HSE back into four, six or eight regions, a much more sensible approach would be to create two national organisations.

One of them would run the 50 hospitals we have in Ireland, ranging from large to small, and be accountable for patient care in the full sense of that term. It would also be charged with continuing the development of a full primary care system.

The other would be responsible for all community and family services. Each would have its own transparent vote and would be able to determine its own priorities.

We’re small enough as a country, and yet diverse enough in terms of need, to sustain two independent national organisations, each focused on results and services rather than on geography.

But that would require a real culture shock. And we’d never be prepared to put up with that, would we?

This appeared in the printed version of the Irish Examiner Tuesday, July 08, 2008