FERGUS FINLAY: Why HSE must mean health serves everyone... we must start again

Emma Mhic Mhathúna

Now is the time for fundamental reform. Now is the time for a massive shake-up of our health system, writes Fergus Finlay.

Now is the time to really grasp the nettle with both hands. 

What it takes is a significant expression of political will — a recognition that our health service has stopped working, in all the ways that matter. 

It doesn’t deliver timely responses to need; it doesn’t treat everyone the same; it doesn’t put patients first in every instance; and it doesn’t deliver value for money.

Look what’s happening right now in respect of our policing system. As I write this, there is a recruitment process under way for a new Garda commissioner. 

The process has been delayed, and it’s unlikely to be completed until the late summer or early autumn.

At the same time as that appointment is being made, there will be a report from a highly independent commission on the future of policing in Ireland.

Side by side with that, we are still awaiting government decisions in relation to the future of the Department of Justice. It too has an acting secretary general, and it too has been the subject of much speculation. 

The likelihood is that (at least) the department will be split in two before the end of the summer.

So the new commissioner of the Garda, whoever he or she is, will have a different master than any previous commissioner. 

He or she will be presented with a blueprint for major reform on their first day in the job. The probability is that there will be a five-year contract, and success or failure will be measured by the degree to which reform is implemented in that time. 

Acting Garda CommissionerDónall O Cualáin
Acting Garda Commissioner Dónall O Cualáin

A key measure of success, one assumes, will be the development of a transparently accountable and scandal-free force.

I would hope, in fact, that the new commissioner would set out to create a policing service, rather than a police force. It’s a daunting task, and he or she will be surrounded by reports and strategies and expectations. 

In many ways, the same thing applies to the health service. There’s a vacancy at the top — in fact there are two vacancies, because the HSE is not just in search of a new CEO, but it desperately needs a new independent and reforming board. 

However, what’s not needed is a new blueprint, because there is one.

The blueprint is SláinteCare, a cross-party report published by, of all bodies, an Oireachtas committee. 

Deputies from all sides — from the Anti-Austerity Alliance to Fine Gael (and there were more FG deputies than any other party) were able to agree on a set of recommendations which would have profound impacts on the future of the HSE, and on the delivery of health services generally, if it were implemented. 

The logical next step now is for the government to do what they seem to be about to do with the Garda Síochána — to appoint a board and a CEO with a five-year contract for reform and change.

I’ve argued here before that the HSE can never function because of its size. It’s a monster that can never adapt to the changing needs of the people it services. SlainteCare takes a slightly different approach. 

It would reposition the “central” HSE as a sort of corporate umbrella, with strategic responsibility for planning and evaluation, and operational responsibility for some core functions, like human resources, financial management and reporting, and communications.

That would enable the health service to be “re-imagined” in regional terms. It would mean deciding on the range of integrated services that are needed on the ground, and managing them regionally.

Former HSE chiefTony O'Brien
Former HSE chief Tony O'Brien

In a sense, that would be a bit like going back to the past, when originally most health and social services were delivered on a county basis. 

That was a much more responsive system, but it was also one that was incapable of dealing with the need for such things as centres of excellence. 

We moved to a more regional system to seek to solve that problem — the problem of local interests always clashing with the best way to invest resources. To a considerable extent, that problem has been solved now. 

If the SláinteCare approach was followed, the big decisions — on issues like cancer care — would be made nationally, but delivery would be much more local.

But the two biggest recommendations in SláinteCare are the things that would make the most profound difference. The first is a cross-party recommendation that would lead to the phased elimination of private care from public hospitals. 

That doesn’t mean doing away with private healthcare entirely — people with private health insurance will still be able to buy private healthcasre in private hospitals. But everyone arriving at the door of a public hospital would be treated exactly the same as everyone else.

If SláinteCare is delivered, arriving at the door of a hospital will be a last resort.

The key recommendation of the report is a significant expansion of capacity in primary care and social care — this includes, among other areas, investment in community diagnostics, primary care teams and mental health teams, services for people with disabilities, homecare services and free GP care.

That would represent a radical shift — something that can’t happen without more money going into the system over a decade of investment. But it could also result in a system that was based on need, not income; a system that was capable of responding to individuals, rather than one that was driven by crisis and scandal.

Over the years that the HSE has existed, and despite the best efforts of some of its key people, it has become less rather than more accountable. 

Minister Simon Harris
Minister Simon Harris

It has been seen increasingly as a vehicle for political trouble, when it ought to be the first place we turn when we’re in trouble.

Now, it seems, it has reached a point where our health system has been seen as imposing terrible suffering on women who trusted it. Its reputation, no matter what it does, is in tatters. It is seen as inefficient, incompetent, remote, sometimes cruel and untruthful. 

That may not be fair — it may not even correspond with the lived experience of people who have been through the health system and come out better for it (I’m one of them and I count myself lucky). But its current indelible reputation is the result of self-inflicted wounds.

In one of her harrowing interviews about her own situation, Emma Mhic Mháthúna said wistfully that she wanted the letters HSE to mean “health serves everyone”. 

But it doesn’t, and sometimes it seems like it never can. The least though that every citizen is entitled to is that health will be accountable to everyone.

That’s why we have to start again. Whatever it takes, the health system has to be rebuilt in terms of trust from the ground up.

That’s why the minister for health must pause now. He shouldn’t be setting out to find some new manager. Instead he needs to set out a detailed, time-lined plan to secure the bottom-up reform of the service. 

If that’s the legacy of the cervical smear scandal, some good will have come from tragedy. 

If it isn’t, we will have failed again.

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