The transparency and accountability the new structure promised back in 2005 never materialised. Now the HSE is being reinvented again, writes
“How do you unscramble a scrambled egg?”
The question was posed by Bernard Allen, a Fine Gael TD in Cork North Central for 30 years who had a similar length of service as a member of the then Southern Health Board (SHB).
He has no clue whether the HSE's latest reincarnation will kill or cure it.
The retired TD sat on the SHB from 1979 until Micheál Martin killed it off, along with 10 other health boards, in 2004. In June that year, the then health minister signed a statutory order transferring the boards’ powers to their chief executives, until the HSE took over the running of the health service from January 1, 2005.
By then Mary Harney was health minister, so she oversaw the HSE’s arrival. You could say that Harney and Martin gave birth to the HSE but were ultimately careless parents, not around to defend it against the whims of subsequent health ministers.
Martin’s justification for setting up the HSE is outlined in his Health Reform Programme speech to the Dáil in June 2003. Two different reports, he said, had reached roughly the same conclusions.
Both reports - one an audit of structures and functions in the health system, the other an examination of financial management and controls - identified the need for structural reform.
Martin pointed out that health board structures were more than 30 years old - set up in 1970 - and had spawned a large range of specialist agencies during that period - 58 to be precise.
He said such multiplicity “has resulted in a complex and fragmented system which has itself become an obstacle to achieving improvements”.
He said both reports “emphasised the need to introduce rationalisation, standardisation and much-improved co-ordination to overcome this fragmentation and to give me, as the Minister, a realistic span of control over the agencies for which I am responsible”.
Martin said the reports also drew attention to the tensions between local representation and decision-making, vis-à-vis national policy objectives. Colleagues of mine who attended SHB meetings back in the day testified to this. Packed with members of Cork City and County Councils and Kerry County Council, including the Healy-Raes, they were an excellent platform for grandstanding and from which to launch national political careers. Not to mention nice little expense earners.
Anyhow, Martin put paid to all that, and the magnificently bureaucratic HSE, with its eye trained on “clear accountability”, “improved budgetary and service planning” and “most importantly, improved patient care” rolled into being on January 1, 2005.
For the first time, the health service would be managed as a single national entity, albeit with a regional structure - HSE Dublin Mid-Leinster, HSE Dublin North East, HSE South and HSE West.
It had a board to hold it accountable, while the Minister for Health retained overall responsibility for the Executive in Government.
The planned transformation didn’t quite go to plan.
Firstly, the notion of rationalisation was knocked on the head on foot of a last-minute deal with the unions which essentially protected jobs.
Health board CEOs became HSE CEOs eg Séan Hurley, CEO of the SHB became CEO HSE- Southern Area, and later, HSE acting National Director of Information and Communication Technology and subsequently head of the HSE’s Corporate Pharmaceutical Unit.
Mr Hurley is not the only example of musical chairs under the formation of the new Executive. In fact there are many. Another good example is Laverne McGuinness.
From October 2009 to December 2012, she was HSE National Director of Integrated Services and was previously HSE National Director of Primary Community & Continuing Care.
Before the establishment of the HSE she worked as an accountant and assistant chief executive to the former Northern Area Health Board. By the time she moved to the private sector in 2015, she had reached the position of HSE deputy director general.
In terms of structures, the HSE started off with three “core” divisions: The National Hospitals Office; Primary, Community and Continuing Care Directorate and National Shared Services Centre.
The Primary, Community and Continuing Care Directorate would comprise of four regional health offices, while at local level, community care structures would be strengthened “to support the maximum local delivery of services and to provide an integrated framework for the development of the Primary Care Model”.
By October 2014, the HSE had decided on nine community health organisations as per the recommendations of a report that “the alignment of health and social care delivery structures with common defined geographical catchment areas makes sense”.
That report was overseen by then National Director Social Care Pat Healy, formerly regional director HSE South, formerly chief officer of the SHB, now National Director, Community Strategy & Planning.
The future structure of those nine CHO’s is unclear following today's announcement that there will be six regional health bodies as part of the latest HSE overhaul. Neither is there any clarity around whether the intention remains to develop hospital groups into Trusts, as was all the rage a few short years ago.
The organising of hospitals into groups was announced in May 2013 by then Health Minister James Reilly, who was not a fan of the HSE. Dr Reilly got rid of the HSE board in 2011 in an effort to make those running the executive more directly accountable to him. His plan was to dismantle the HSE and focus on introducing universal health insurance, a plan that was, for a time, backed by his successor in health, Leo Varadkar.
Mr Reilly’s antipathy towards the HSE is reflected in a speech in 2012 when he described Mr Martin as “the designer in chief of a new health service where he created an unaffordable, unsustainable and grossly inefficient bureaucracy”.
“So instead of getting the normal efficiencies that one gets from merging 11 different companies and reducing overheads we got all the idiosyncratic inefficiencies of 11 different health boards.
"That still haunts us to this day in terms of financial reporting mechanisms, different ways of counting things, different ways of coding things – information that’s nigh on impossible to analyse,” he said.
The proposed new six #health areas which, we are told, will have more autonomy & be more accountable under healthcare reforms. Minister @SimonHarrisTD will explain more shortly #iestaff see @irishexaminer via @Junomaco pic.twitter.com/WdrvX2Sl6t— Irish Examiner (@irishexaminer) July 17, 2019
There are many aspects of the HSE that continue to be well-nigh impossible to analyse. The transparency and accountability the new structure promised back in 2005 never materialised. Now the HSE is being reinvented again. It has a new board, its structures are about to be overhauled and it has a roadmap in the form of Sláintecare.
According to Health Minister Simon Harris, the revamp "will result in clear financial and performance accountability, empower frontline staff and devolve authority from the HSE to the local regions". According to HSE chief Paul Reid, it won't mean more managers.
The devolution of power is the easy part. The other aspirations have never been delivered and given the HSE's track record, are likely to be no less tricky than unscrambling a scrambled egg.