CATHAL Magee is the new kid on the HSE block. This week he embarks on the most challenging public sector role of delivering on patient safety and timely care.
His immediate mandate is to secure more treatment output with less resources. Public health expenditure peaked in 2009 at €15bn. The target next year is a ceiling of €13bn, despite a growing and ageing population with consequent extra health demands.
The HSE will be six years old next January. It replaced eight regional health boards, delivering localised community and hospital care. The theory was centralising into a single structure would rationalise management, effect greater efficiencies, harmonise standards and achieve economies of scale.
Critics allege an incoherent, bureaucratic monster has resulted. It has not lacked for finance. In 1997 health expenditure was a quarter of its present level – an extra €10bn has been provided. This amounts to 27 cents in every euro of public expenditure. This pays for 50 acute hospitals within four regions, more than 17,700 non acute care beds and 650 health centres.
The biggest failing of the HSE has been its inability effectively to communicate a core strategy and explain deliverable objectives. There has been an absence of leadership at board and top management level to explain clinical priorities, health prevention targets and create an understanding of its constraints.
Media and political debate on health is based on the latest atrocity. Coverage is confined to episodes of trolley horrors, long waiting lists, industrial disputes, diagnostic disasters, cashflow crises and individual tragedies. The HSE is cast in the role of fire brigade responses. Politicians seek opportunistically to maximise anxieties. This is complemented by vested interests pedalling their own propaganda.
Cathal Magee urgently needs to set out the complete context of achievable expectations and limitations. He needs radically to change the culture whereby the HSE systematically conceals crucial information such as the deaths of children in its care. The era of the cover-up needs to end. Defensive media briefings, dislocated statements and rare appearances at Oireachtas committees need to be replaced by a personalised leadership style. The increasing reluctance of Health Minister Mary Harney to appear has exacerbated a hopeless and hapless presentation of the public health service.
Her strategy is that any failing is the fault of the HSE, while accountability is a matter for the Health Information & Quality Authority (HIQA). The Department of Health and her office are charged with policy development, but seemingly with no oversight role or responsibility. Her health reform agenda has dried up. Initiatives such as hospital co-location, consultants’ contract reform, Fair Deal nursing home scheme, National Treatment Purchase Fund and risk equalisation of health insurance have run their course. Harney seems content to serve out her tenure with few new ideas other than lethargically presiding over obligatory budgetary cutbacks of €700m at arm’s length.
The opposition parties have a dual strategy. On the ground in each constituency they lead campaigns for the localised retention of services and resist cutbacks. At national level, both Fine Gael and Labour advocate universal health insurance. This promises the abolition of a two-tier system, fairness, efficiency, transparency and reduced costs.
FG’s FairCare proposal specifically promises free GP care package for all and a slashing of hospital waiting lists. Who will pay for this utopian outcome? Will our VHI bills soar to pay for medical card-holders’ requirements? Does universal insurance mean more tax subvention? There has been no detailed debate or explanation of what is our optimum health system – a duplicate of Britain’s NHS, Obama-type reforms, a market-orientated competitive provision system or some form of hybrid. Instead, we have sham health politics.
The HSE is charged with a miracle of the loaves and fishes, procuring more with less. A template for this agenda is the Bord Snip report. They advocated a reduction of 6,168 in staff numbers (from 111,000), saving €300m. The axe was to fall on administrative staff.
Since the health boards were replaced, 2,900 extra non-frontline staff were recruited. They identified further efficiencies to save €90m. Perhaps their most innovative recommendation was to open up to competitive tendering the provision of services under the GMS.
GPs, dentists and other service providers could obtain volume via price reductions. Greater use of generic medicines and a variety of extra charges (from prescriptions to A&E admissions) would eliminate wasteful costs. Various quangos were to be merged. No formal political response emerged to these measures.
Cathal Magee should become a health tsar, raising the dialogue of our non-existent national health debate. There are truisms about healthcare. Early detection, based on best diagnostics, leads to higher cure rates. Comprehensive prevention plans relating to diet, exercise and regular check-ups reduce ultimate treatment costs and increase life expectancy. Integrated procurement means cheaper costs of all supplies from toilet rolls, linen, medicines, heating and stationary. Primary care in the community operates at a fraction of hospital costs. Effective bed management depends on early release, five-day-week hospital management rosters and more day hospital facilities. The elderly prefer independent living at home, only achievable with proper homecare supports.
Vision, mission and strategy on health policy and delivery are absent. Rhetoric about patient focus and value for money is glib. Surely the greatest cost imperative is to centralise acute hospital services along the lines of the four cancer control networks. The Hanly report of 2003 recommending hospital consolidation gathers dust. Change is often confronted in the context of crisis.This takes the form of budget overruns at year end. Only a €91m overspend in HSE West prompts hospital reorganisation in the region.
BECAUSE PPARS was a fiscal fiasco, we fail to obtain the smartest information technology application in healthcare. Does the new hospital consultants’ contract deliver for the patient or clinician?
We need an implementation taskforce to expose and weed out the poorest units of inefficient management. We as taxpayers and patients are entitled to know if there are duplicated diagnostic tests arising out of the Data Protection Act. We need clarity whether primary care teams are a reality on the ground or more bureaucratic spin. Outsourcing could significantly reduce a range of hospital general running costs – it’s taboo. Clinicians can be deployed more effectively to act as gatekeepers to costs, prioritising medical needs. It transpires nurses are being replaced by agencies at 35% extra cost, sometimes with the same individuals. Positive mental health programmes are token. A sustainable health service is based on affordability.
We face a winter of deep discontent within the health service. Outright rejection of all cutbacks may shield efficiency gains and the requirement for change. Our health challenges are the same as those in every other developed state. It’s not rocket science. We as taxpayers and patients are entitled to a forum for reform. A Tallaght Strategy is necessary to achieve a consensus for what is our greatest public service task – it’s called the national interest.
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