Departmental role key to proper reform of health service, says 2019 report

A REPORT that was supposed to provide a roadmap for the Sláintecare team warned that ‘­competing interests’ posed a significant threat to attempts to decentralise the health service, the Irish Mail on Sunday can reveal.

The report by the Health Research Board (HRB), drew on international research to identify barriers and problems that six other countries had faced when they decentralised their health services into Regional Health Organisations (RHOs).

The HRB research, commissioned for the Sláintecare project by the Department of Health, was supposed to guide health service leaders here and help them avoid pitfalls encountered elsewhere.

‘­There is some evidence to suggest that a regionalised healthcare system could ultimately lead to a healthy population and an efficient health system,’ the report said.

‘­However, policy-makers need to consider the important barriers, to and facilitators of, effective implementation.’ The research was completed in 2019 as the HSE and Government approved and announced the geographic breakdown of six new regional health areas.

Chief among the research findings was that an ‘­overarching’ barrier to similar restructures elsewhere had been ‘­tension between RHOs and the MoH (Ministry of Health) regarding their competing interests’.

Key conflict areas, the report found, included the way in which funding and management responsibility is allocated from Government, via a Ministry of Health, to regional health authorities.

And this is precisely the point at which Sláintecare’s regionalisation plans have stalled.

The report also identified how regionalisation causes tension and conflict among key actors like healthcare bosses in various different organisations.

‘­Regionalisation involves major shifts in the roles and responsibilities of key actors in the health system, and as a result, the implementation process is marked by tension,’ the report reads.

‘­Clear roles, responsibilities, and accountabilities, particularly between the MoH and RHOs, are crucial,’ it continued.

The report also warned that health ministries must play a key role in supporting the emergence of new regional authorities.

‘­This support can lay the foundation for close working relationships between the MoH and RHOs, which could contribute to the viability and sustainability of RHOs in the long term.’

However, as the fall-out from this month’s shock Sláintecare resignations showed, these warnings appear to have gone unheeded by health authorities.

Instead, the HSE and the Department of Health (under Secretary General Robert Watt) have this week been accused of ‘­institutional resistance’ by political and health leaders.

‘­We urgently want to hear what exactly were the reasons for these resignations, what were the obstacles put in the way of reform and what is the minister going to do to remove those obstacles,’ said the co-leader of the Social Democrats, Róisín Shortall.

Deputy Shortall was Chair of the all-party Oireachtas Committee that drew up and agreed the Sláintecare plan in 2017.

An apparent institutional resistance to aspects of Sláintecare was also referred to directly by those who have now resigned.

Departing Sláintecare Executive Director Laura Magahy’s resignation letter to Health Minister Stephen Donnelly cited ‘­slow progress’ in implementing regional structures.

Professor Tom Keane – Chair of the Sláintecare Implementation Advisory Committee (SIAC) – cited the ‘­fundamental failures of governance, accountability and commitment’, in his own letter of resignation. ‘­These’, he said, ‘­continue to make any chance of success impossible.’

A third resignation – that of South/ South West Hospital Group Chair, Professor Geraldine McCarthy – cited similar concerns.

‘­It is regrettable that much of the needed reform of the health service has not been delivered,’ Professor McCarthy’s resignation letter to Mr Donnelly reads.

‘­I have waited for a long time for developments led by successive ministers for health and government. However, recent information and my own experiences tell me we are no nearer to the required reform than we were six years ago.’

A Sláintecare progress report, showed that the regionalisation of the HSE was one of just three aspects that have effectively stalled. The other two Sláintecare aspects facing ‘­significant challenges’ – according to the progress report – are plans for ehealth initiatives and efforts to reduce waiting lists.

Since the resignations, the Government and the HSE have been stoutly defending their commitment to Sláintecare and regionalisation – something they have not always done.

Speaking this weekend, HSE CEO Paul Reid acknowledged that ‘­regional structures are a key part of Slaintecare and have to be implemented and we are – for the record – duly committed to implementing that.’

‘­There is an absolute consensus amongst all of us that we want to move to a regional structure. The issue is what the design of that looks like and how we go about it,’ Mr Reid added.

But a year ago, in an interview with the Sunday Business Post, he said something very different.

‘­My primary message is that if we are considering what to prioritise, then the regionalisation should not be up there,’ he said.

‘­There is one big lesson I have learned from Covid-19, which is that the role of the centre of the HSE has become a lot clearer. We gave direction and clarity from a high level and let the system get on with it then. That is the big lesson.

‘­If we were operating in six regions, with six boards all around the country, would we have achieved that pace and that singular focus and direction? I would question whether we would have.’ Minutes of SIAC meetings also show that in September 2000 Mr Donnelly effectively roadblocked regionalisation progress until Covid had ended – which SIAC members strongly opposed.

‘­The minister believes the health systems need to be stabilised in order to get through Covid-19,’ the SIAC minutes read.

Mr Donnelly told the September 2020 SIAC meeting that he would ‘­look at reorganisation in due course’ but that it was not a ‘­risk’ he was prepared to add to the system during the pandemic.

In the wake of this month’s resignations, SICA member and former Irish Nurses and Midwives (INMO) boss Liam Doran appears to have encountered this attitude first hand.

Speaking after meeting Mr Donnelly last week, Mr Doran said: ‘­I came away from the meeting no wiser as to why the two people had resigned, and not imbued with any sense that the Government and the minister gets the seriousness of the resignations.

‘­I also didn’t get the sense that the resignations were going to trigger a review of how they do things and address the pace of reform.’

Meanwhile the Oireachtas Health Committee wants to hear directly from those that resigned – though at present Professor Tom Keane, who is based abroad, is unavailable, while Laura Magahy is on leave.

However, it is expected next week’s committee meeting will hear from Professor Geraldine McCarthy who will be asked to expand her reasons for resigning.

Patient advocates, meanwhile, have told of the exasperation at how the political system continues let down those most in need.

‘­It’s a failure by the body politic,’ Stephen McMahon of the Irish Patients Association told the MoS.

‘­They all agreed to it. They all signed off on it and now, when it gets to the implementation, once again wonderful promises of journeys to the promised land just disappear in smoke.

‘­I think it’s absolutely appalling. I think it’s just so sad,’ he said.

‘­As a patient advocate, what I’m saying to the Taoiseach, the Government, the HSE and the Department of Health – and all the political parties and the powerful vested interests within the healthcare system – is sit down, bring patient advocates in there around the table and get this sorted out,’ he added.