Mr. Tony O'Brien:

My comments on the structural issue were not intended to close off discussion but to stimulate it. It is my view, as it would be that of other people in similar roles in other jurisdictions, that there are no perfect structures and that whatever structures we have at any given time, it is always possible to argue that a different structure would be preferable. There is also, however, very significant evidence from restructuring processes around the world of the impact of restructuring. Following a study of the context and processes of the mergers of health care providers in England, Professor Naomi Fulop has produced a report which shows that structural changes typically lead to delays to service improvements of at least 18 months, that there tends to be a loss of managerial focus on services leading to a risk to patient safety and that the expectation of cost savings, generally speaking, are not realised.

A satirical study, A Surrealistic Mega-analysis of Redisorganisation Theories, made the serious point that, around the world, one can observe a pattern across many countries whereby one poorly planned, top-down restructure invariably leads to another. We are well into a process in which the hospital groups, in particular, are beginning to bear fruit in terms of the alignment of services, as are the CHOs. If we decide to stop that there will be a price to be paid, as there was when the eastern regional health authority was stopped before it got to a certain point. We will not necessarily be able to produce a structure to replace it which would be perfect, or less imperfect, than what we currently have.

We are spending a very substantial sum of money on health and there is an opportunity, through some of the processes currently under way involving groups and CHOs, to use the funding better by the realignment of services. I am not saying we need to spend an ever-increasing amount on health care.

In order to allow strategic change planning, we need to plan ahead over a longer time horizon than we do. For example, the HSE did not know what its budget for 2017 would be until budget day, and, as it stands, it will not know its budget for 2018-----