That Seanad Éireann:
notes the continuing problems and regular crises in the management and operation of our health services, and believes that the HSE is not working;
further notes that the HSE has failed to meet any of the original objectives set by the Government, namely, to make the system more responsive to the needs of patients, to make the system more accountable, and to provide better value for money;
believes that rather than improving, the situation is in fact getting worse, and that we now have a monolithic system, distanced from the patient, divorced from ministerial accountability, and driven by budgetary concerns rather than patient need.
Accordingly, Seanad Éireann calls on the Government to initiate without delay a recovery plan for the HSE consisting of the following six steps:
1. establish clear lines of authority, responsibility and reporting within the HSE, with standard-setting at national level and as much day-to-day decision making devolved to local level as possible;
2. make the Minister for Health and Children answerable to the public through the Oireachtas for all aspects of health service policy and delivery, and make the Secretary General of the Department the Accounting Officer for the HSE;
3. offer a voluntary early retirement, redundancy and re-deployment scheme, as part of the rationalisation of management structures;
4. give each hospital and each community care area autonomy to spend its budget, allocated according to national norms. Require each hospital to establish a management board;
5. accountability to the public through local and national public representatives should be at network and community care area rather than regional level and regional structures should be abolished; and
6. each hospital and community care area should be required to establish a patient liaison programme in accordance with recommendation 11 of the HIQA report on Rebecca O'Malley's case.
I wish to extend a warm welcome to the Minister. However, I do not believe she will be feeling quite so warm towards me when I have concluded my contribution.
For the past three years we have watched with keen anticipation the workings of the Health Service Executive, HSE, which was established with reference to the Health Act 2004. The latter provided a legal framework for the establishment of a body to assume responsibility for the management and delivery of health services from the various regional health boards that were then in place. We were informed that the HSE pledged "to use the resources available to it in the most beneficial, effective and efficient manner to improve, promote and protect the health and welfare of the public". This is a noble and ambitious challenge, in respect of which, unfortunately, the HSE has already failed. Since January 2005, the HSE was supposed to manage all the varied aspects of the health service in a co-ordinated and cohesive manner in order to ensure better quality of care. Consequently, this was to ensure that the health of all members of society would be enhanced in a whole-of-Government approach to health care.
Unfortunately, the reality of our ailing health service is a far cry from the brainchild conceived by the Minister. Services are being cut and relocated in a unilateral fashion, with no meaningful discussion with interested parties such as front-line employees and those availing of the service. In south Tipperary, breast care services were transferred in a heartbeat to Waterford Regional Hospital and, while this matter was no doubt discussed at length, the final decision was announced as afait accompli to the people of Tipperary when the service had already been transferred. There was no opportunity for a local public perspective on the issue. The experts had made their decision, regardless of the disruption this brought to women who were experiencing serious health problems and who were undergoing invasive and stressful treatment. Consideration was not given to the distances their concerned families would be obliged to travel in order to be present to support their loved ones.
Waiting lists are spiralling out of control to such an extent that many essential services are now only partially available to those lucky — I use the word advisedly — enough to have a place on them. Even then, there is no guarantee of the level of service that people will finally receive because there is a concerted effort to simply clear the waiting lists through one-off assessments and referrals to other services. This will undoubtedly lead to even more waiting. Many waiting lists have been temporarily closed due to the inability of the health service to provide the necessary resources.
The HSE has already overspent by €95 million in the first four months of this year. AsThe Irish Times and other newspapers have reported, the situation is becoming worse on a daily basis. The executive’s attempt to address this problem through staff embargoes, limiting recruitment in particular areas to the financial constraints that apply in those areas and cutting vital services has simply resulted in further difficulties and nationwide dissatisfaction. All those who work in front-line services are feeling the brunt of these decisions. Morale has been badly affected, sick leave has spiralled and, given that the size of the workforce in the health area has been dramatically reduced, staff are finding it impossible to deliver the desired level of care and service.
The Labour Party has studied the difficulties associated with the management of the health service and acknowledges that reversing the current position will pose a considerable challenge. We are, however, convinced that the six-point plan I will outline will have a positive impact and return this service to the core values required to provide an equitable and responsible health service that will serve the needs of the people. To implement the plan, it is essential the Government and the HSE recognise the need to address core issues such as the need to increase bed capacity and, as a matter of urgency, to finalise the consultants' contract.
The six steps in the plan are: to establish clear lines of authority, responsibility and reporting within the HSE, with standard-setting at national level and as much day-to-day decision making as possible devolved to local level; to make the Minister for Health and Children answerable to the public, through the Dáil, for all aspects of health service policy and delivery and to make the Secretary General of the Department Accounting Officer for the HSE; to offer a voluntary early retirement, redundancy and redeployment scheme, as part of the rationalisation of management structures; to give each hospital and each community care area autonomy to spend its budget, allocated according to national norms and to require that all hospitals establish management boards; accountability to the public through local and national public representatives should be at network and community care area level rather than at regional level, and regional structures should be abolished; and each hospital and community care area should be required to establish a patient liaison programme in accordance with recommendation 11 of the HIQA report on the Rebecca O'Malley case.
To deliver effective health care, we must start with the patient. This means we must consider the available budget and ensure there is a fair allocation of funds to all areas of the country and that these funds are spent in a meaningful way at local level. Local management teams must then be allowed to take charge of this money and direct it into the services required. There is no doubt the local management teams in our hospitals are best placed to decide the level of funds to be allocated for the range of services provided. A degree of autonomy will undoubtedly result in better management of funds. Local managers surely have the wherewithal to assess the service needs, prioritise spending and ensure the continuation and development of core services. There is no necessity for a three-tier system of management because, as a result of the level of devolvement, this ultimately leads to complete confusion and a marked lack of personal responsibility for budgets.
The structure of the HSE, as it stands, is a source of great confusion. Decisions are made and nobody seems to know who was responsible for them. Again, simple decisions that impact locally should be discussed and made at ground level, with the necessary accountability built into the system. Once the bulk of local decision making has been delegated to the direct management, more time and energy can be given by the leadership of the executive to developing standards that will facilitate the effective implementation of the policies of the Department of Health and Children. This will ultimately result in a transparent, accountable and responsible health service.
At present, it is almost impossible to obtain a direct answer on any issue from the Department of Health and Children. This is largely due to the way the HSE and the Department work hand in hand. It was initially envisaged that the Department would be responsible for the formulation of policy, while the HSE would oversee the implementation of such policy, However, there is so much overlapping between both structures that there are no clear lines of definition. This is an enormously grey area, with the Minister involving herself with the implementation of policy and, equally, the management of the HSE wandering into the area of policy formulation.
The HSE and the Department need to work as separate and individual entities which complement each other but which also allow each other to advance their own areas of responsibility in an independent manner. Consequently, each entity must be separately accountable for the decisions made and should be available to justify these policies and decisions to the Members of the Oireachtas. The Minister for Health and Children must ensure that budgets for new development and policy focus, as recommended in the document A Vision for Change, should be specifically earmarked for this purpose and not redirected to address budgetary deficits. If the overall standard and delivery of care by the Department and the HSE is to be improved and refined, these funds will have to be protected to ensure development of new and innovative strategies.
The next point is the offering of a voluntary early retirement, redundancy and redeployment scheme. The original formation of the Health Service Executive brought together many different strands involved in the management of the health service. However, all the pre-existing levels of management were simply brought forward into the HSE, with much duplication of responsibility and the resultant layers of administration that prevent the development of a streamlined organisation. It is clear that in the interests of removing unnecessary inherited layers of administration, an agreeable redundancy package must be introduced. While there will be an initial outlay associated with this redundancy package and early retirement scheme, the long-term benefits not only will leave additional funds in the coffers for essential services but also ensure each respective layer of administration can work efficiently and in a productive manner.
The next point is the strengthening of decision making at local level. Once again, the present structure of the HSE removes decision making from those who invariably implement the decisions locally. Independent administration of the annual budget by a committee made up of members of the multidisciplinary team in each hospital will make for a personalised approach to spending where each member has a vested interest in prudent spending to maximise the returns from funds, and it will facilitate the prioritisation and development of important resources in each of the separate areas. It is recommended that these committees would also liaise with other hospitals, forming a regional network, and with representatives of primary, community and continuing care.
Labour favours the introduction of universal health insurance as part of the overall reform of the health service. For universal health insurance to work effectively, it is necessary to strengthen local management and decision-making structures, and to enhance corporate governance at hospital level. These kinds of reforms, therefore, will contribute in the long run to a more effective use of resources in the health service.
The next point is the restoration of local accountability. Labour is proposing that the present regional structures in the HSE be abolished and replaced with a new system of accountability. In respect of hospitals, this would be located at the hospital network level and would involve local and national public representatives who would meet regularly and have the power to insist that health officials attend meetings and answer questions. The focus would be on delivery of services. In respect of social services, there would be a structure in each community care area which would similarly invigilate the delivery of social services and where public representatives could hold local social services to account, again within budgets set out by the HSE and according to national norms.
The next point involves a patient liaison programme which each hospital and community care area should be required to establish in accordance with recommendation 11 of the Health Information and Quality Authority report on Rebecca O'Malley's case. We are all aware of the repeated failures in patient diagnoses over recent years and a way forward must be put in place to ensure such systems failures do not recur. What has emerged arising from these incidents has been the urgent need for a strong clinical governance procedure and also for the development of a patient liaison programme. This was identified by the HIQA in the report on the Rebecca O'Malley case and forms one of the key recommendations.
Labour advocates the appointment of an independent advocate as well as a hospital-appointed dedicated patient liaison person as part of a complaints procedure. This will ensure patients will have somewhere to go should they have any concerns. It is essential that this recommendation be implemented as soon as possible primarily to ensure patients' health risks are reduced and also to restore public trust in the effectiveness of our health service.