Mr. Leo Kearns:

I thank the Vice Chair and the committee for the invitation to attend. In late December 2021, the Minister for Health established the regional health areas advisory group and appointed me as independent chair of this group. The membership of the group includes people of great experience from right across the health and social care system. It is important to note the role of the group is to provide advice. The responsibility to draft the plan and to implement regional health areas, RHAs, rests with the HSE and the Department of Health. An implementation team has been established under the joint leadership of the Secretary General of the Department of Health and the CEO of the HSE.

I will give a little bit of background, which I am aware members are very familiar with. The six new RHAs are in line with recommendations made in the Sláintecare report published by the Oireachtas Committee on the Future of Healthcare in 2017 that regional bodies should be responsible for the planning and delivery of integrated health and social care services. Integrated care is where services, funding and governance are co-ordinated around the needs of the patient, encompassing both acute and community care. RHAs will ensure the geographical alignment of hospital and community healthcare services at a regional level based on defined populations and their local needs. This is key to delivering on the Sláintecare vision of an integrated health and social care service. As well as enabling the integration of community and acute care, RHAs aim to empower local decision-making and support population-based service planning. This will ultimately strengthen our health service and lead to improved patient experience as well as access to healthcare closer to home. Since its formation, the advisory group has met on a number of occasions and I will outline some of the key pieces of advice provided.

Ensuring clarity of purpose is one aspect. The core vision driving RHA implementation is to improve care to patients by enabling a joined-up, integrated approach to service planning and delivery and to empower those who deliver that care. There is still a significant risk RHAs are being viewed primarily as an organisational, back-office type exercise. If this perception remains, then this reform programme will be undermined.

I will speak a little about governance and accountability. A key issue at the heart of the RHA implementation is the belief that the current centralised and hierarchical governance approach to the health service needs to change fundamentally and radically. It is not possible to define a clear role for an RHA without also doing the same for HSE centre and for the Department of Health, and this includes how all these entities relate to each other. The guiding principle that should underpin this work is that of subsidiarity, namely, there should be a guarantee of independence and authority for the RHAs commensurate with the responsibility they are being given, with absolute clarity as to how an accountability framework will work, and the same should apply to HSE centre in relation to the Department of Health. As a natural consequence of that principle, the plan to implement RHAs must also include an aligned change plan for HSE centre and for the Department of Health. In determining the levels of authority that should be delegated, the bias should be towards providing maximum devolved authority sufficient to allow the RHA to exercise effective decision-making to deliver on its responsibilities while working within relevant national frameworks. The only authorities that should be retained at national level are those that are necessary to be retained at national level, and where they are retained, there should be an explicitly stated rationale as to why this is the case. I should state also that there are authorities that should stay at national level. I will speak about that later.

The next aspect is leadership and organisation. Each RHA will be a very large and complex entity within the national health service. It will serve a significant population with a budget of multiple billions, have tens of thousands of staff, and be responsible for the planning and oversight of integrated service provision incorporating prevention, primary care, community, specialist and acute care. It will be responsible for all aspects of care, including mental health, children and older persons' care, and will have to plan and deliver these services across multiple national and local service providers, including voluntary and private providers, and develop integrated service provision with other sectors such as local authorities. Thus, an RHA will be a very significant organisation by any standards. In this context, it is essential the core leadership team for each RHA be appointed as soon as possible to take ownership of the implementation from the perspective of the RHA. A reasonable aim could be to have the recruitment of RHA CEOs commence early in 2023 with a view to the appointment of the core leadership team by the middle to the end of 2023.

Given their scale, there is a risk that RHAs themselves could become centralised, top-down organisations, and simply introduce another bureaucratic layer to the health service. Therefore, the principle of maximum devolved authority also needs to be translated into the organisational arrangements within the RHA. This must ensure appropriate levels of authority for decision-making at the level of the patient pathway and enabling local and regional structures to enable relationships and trust-building across boundaries in acute, community, and other areas. We wish to emphasise this point, as the core rationale for RHAs is to enable integrated pathways of care to patients and clients. Thus, any RHA that does not organise itself in a way that devolves relevant and necessary responsibility, authority, and accountability as close to the patient pathway as possible, will not be fit for purpose. In order to provide clarity and avoid varying or conflicting understandings on this matter, it is important to establish at an early stage the level of authority devolved to RHAs for finance, HR, ICT, estates and so on., and then some basic models as to how this will be operationalised, bearing in mind the principle of subsidiarity mentioned earlier. This will, of course have implications for service planning, budget allocations and care group funding, and will have to provide for transition periods and nuances such as care provided across RHA boundaries, or where services are provided nationally and drawn down regionally. It will have implications for the role of the HSE centre and the Department of Health in relation to finance, HR, ICT and so on, which will have to change from current practices. I should emphasise as well the importance of ICT and data as a critical enabler of integrated care.

The national clinical programmes have been a success for the health service in recent years. In the context of the RHAs and the reformed role for the HSE centre, these frameworks and models will assume a much more fundamental responsibility within the HSE centre, and the development, enhancement, and expansion of these should continue. There are many excellent examples of such frameworks, for example, the national cancer programme, the integrated care programme for older persons, chronic disease management and so on, which demonstrate many of the characteristics of an effective national framework.

I want to mention workforce planning and human resources. At the heart of the motivation to implement RHAs is the concept that this will enable services to be designed and delivered in an integrated way to meet the needs of people at local level. Right across the health service, people will buy into this as a concept worth committing to. However, without staff, this vision will never be realised and people understand this also. It is important to acknowledge that this exercise is taking place at a time when we are experiencing a workforce crisis at many levels. Therefore, it is necessary to establish a credible, sustained, cross-system approach to a multilayered workforce strategy. Failure to make parallel progress on this will fatally undermine efforts to implement RHAs, as it will indicate to people that the implementation of RHAs is not serious about the delivery of better care. There must also be an acknowledgement that for many and varied reasons there is a deficit of trust and a strong sense that people working in the health system do not feel valued. We need to improve the culture in our health service in order that we rebuild trust among staff at all levels. Doing so will help to create the sense that people are valued. Inherent to this culture change is ensuring that staff are included in all changes that will impact upon them in order that they have confidence in the direction of travel. This is key to successful change and not addressing this poses a risk to successful RHA implementation.

I will mention a little bit about engagement. The implementation of RHAs is not simply an organisational or administrative change within the HSE, it requires systemic change, and involves multiple parties. These various entities must be fully engaged in the design and implementation of RHAs. Simply presenting them with a fait accompli will not work. Therefore, thought must be given as to how these organisations and entities will be meaningfully involved, and not just communicated with, from the beginning and throughout the lifetime of this implementation in order that they are part of leading the change.

Implementing RHAs is an extremely challenging and large-scale change. It is not credible that change of this magnitude can be managed without a significant investment in an implementation support infrastructure. While the leadership and drive for the implementation must come from within the system, they must be supported by thought leadership, research, specialist expertise and change and programme management from outside as required. Significant project support and specialist expertise is required at Department of Health, HSE centre and RHA level and must be co-ordinated across all three. It is difficult to see much real progress being made on implementation unless senior leaders in the HSE and the Department of Health are freed up from some of their business-as-usual responsibilities to devote significant thought and time to this.

While work is ongoing to draft the implementation plan, there is also a need to draft a critical path plan based on the key milestones so that it is easier to visualise and understand the critical and main steps in the pathway to implementation. The critical path plan should be shared and communicated widely. Transparency will be vital in building confidence, trust and support. Progress towards implementation should then be evaluated against this critical path plan.

The implementation of the RHAs is essential if we are to set ourselves up to deliver joined-up care to our patients and clients. This is not a simple task and will require significant sustained investment and outstanding leadership at all levels, but particularly at national level to make it happen. We must stop depending on short-term, reactive solutions to crisis situations, and must commit to making the fundamental reforms that are necessary to allow us to develop sustainable solutions to the very real problems we have in our health system. I extend my thanks to the RHA advisory group members for their enthusiastic engagement and I again thank the committee for its invitation today.