New HSE health regions plan: Will it really deliver much-needed healthcare reform?
How health and social care responds to population changes must be a key priority of health regions.
On the final day of July, the Department of Health published the HSE health regions implementation plan. The rollout commences in February 2024 and significantly changes the delivery of our health and social care system.
But does it really? The plan, on first look, screams the return of the health boards structures established under the 1970 Health Act. Initially, eight health boards were established before increasing to 11 in 1999.
They were scrapped for a more centralised system in 2005 with the establishment of the HSE. The reason for the establishment of the HSE at the time is that it would reduce costs and duplication of roles and to improve inconsistencies in the services provided.
The new HSE health regions plan sees the introduction of six health regions as part of the broader Sláintecare plan. Each new region is aligned to serve a population of about 300,00 people.
For example, Cork and Kerry are reunited again as per the previous iteration of the Southern Health Board becoming HSE South-West. HSE West and North-West is a large area covering Donegal, Sligo, Leitrim, Roscommon, Mayo, and Galway.
The overall vision is universal healthcare. The plan outlines a much-needed alignment between the hospital groups and the communities within a defined geographical area. This is a welcome shift.
However, on review of the implementation plan, many grand statements are made on the impact of integrated care. Including a definition of integrated care that involves: “acute, primary, community and social care services / local authorities and involves public and private providers; patients and service users, and their families and carers; health and social care professionals; and the voluntary sector”
With this level of named partners, I searched the plan for outcomes that involve these partners. The measures are narrow and focused on the usual suspects of “hospital length of stay, reduction in delayed transfer of care, hospital avoidances and hospital readmission rates"
Thousands of published articles are available on integrated care. Notably, there is lots of caution on the overall impact. The literature notes it helps if you recognise from the start that integrated care occurs in messy environments and is very complex to implement and lots of micro-politics occurs. Overselling its impact should be avoided.
No mention is made in the report, for example, how integrated care will change how teams will deliver care. How will staff be supported and retained? How will broader population health measures be captured and implemented?
If local authorities are considered partners, will housing be linked with health? How will climate change and environmental planning be deemed to support liveable active communities? How will health equity be measured and tackled? How will the public drive changes in their communities within the governance structures?
The published literature notes integrated care is often understood and experienced differently by different partners. The experience and options of integrated care will be remarkably different for those in West Kerry than in West Dublin. The plan makes no mention of these regional variations.
Take the care of older people. Receiving hospital avoidance interventions such as physiotherapy in your home after 5pm on a Friday in West Kerry is currently magical thinking due to recruitment and retention issues. Most older people cannot access respite or convalescence in Dingle Community Hospital as there is not enough staff. Home help options are also limited.
Availability of affordable housing or rent is a significant factor in staff recruitment. According to the recent 2022 census, Dingle and Ballyshannon in Co Donegal have the oldest population for small towns in Ireland. How health and social care responds to these population changes must be a key priority of health regions.
Stating conditions are essential for any plan. Within the integrated care academic literature, integration failure occurs when there are bureaucratic centralised command and control governance and management structures.
The health regional implementation plan provides an excellent example of this and is a cause of concern. Notably, the plan sets out that the regions will have six regional executive officers on a salary link to a hospital consultant of up to €257,000.
These officers will report directly to the HSE chief executive and become part of a new senior leadership team. Lacking in detail is the role of accountability. How will executive officers in each region support open disclosure and prioritise a learning system?
Mention is also made in the plan of a refined HSE central management team. Their roles are outlined as undertaking tasks such as “co-developing” “planning”, “directing” and “delivering”. It’s unclear how this is different to the role of the Department of Health, and the chance of blurred lines and duplication seems very likely.
In the UK, the recently published Hewitt report undertook an independent review of integrated care systems. The review should provide a clear focus for the development of any health region. The report stresses the need to have fewer central targets and enabling local variations that local communities define as important to them.
Notably, it emphasised the need to move away from a culture of top-down performance management to one of learning and improvement. The current HSE health regions plan reads much more of the same.
It lacks the details to tackle the centralised command and control structures and the measures of success are currently very limited. Now is the time to refine these starting conditions, learn from others and embed the public into the governance structures to support local, responsive and adaptative systems.
- Dr Éidín Ní Shé is senior lecturer at the Graduate School of Healthcare Management, RCSI
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