Michael Harty (Clare, Independent) | Oireachtas source

The Health Service Executive (Governance) Bill 2018 is extremely important and I welcome it because it is at last introducing real structural health reform. It reflects one of the main recommendations of the Sláintecare report which was published on 30 May 2017. It has taken 20 months to introduce legislation to reappoint the board. It is very disappointing that it has taken almost two years to bring the legislation forward. That is indicative of the slow pace of implementing Sláintecare reforms which is disappointing given that Sláintecare has cross-party support. Nevertheless, it is a welcome start.

The Bill is a significant reversal of Government policy which was initiated in 2012, as Deputy Connolly so clearly explained, by Senator Reilly, the then Minister for Health, who disbanded the HSE board on a whim. I think it was his intention to disband the board within 100 days of being appointed Minister for Health. This intention to replace the board was never realised and the structures put in place, the clinical directorates and the civil servants who replaced the board members, never really worked. That has contributed to the demise of our health service that we are experiencing today.

A Programme for Partnership Government published in May 2016 which underpinned this Government included a commitment to continue to dismantle the HSE and replace it with a new structure. Thankfully, that new structure has not appeared. In the Oireachtas Joint Committee on Health's deliberations on Sláintecare we were advised by many experts in change management that if we were to reform our health service, we should do so with the minimum structural change possible because once major structural changes are made, it takes years to implement them. The recommendation was to reconstitute the HSE board and work from within the HSE to reform the health service, rather than setting up a new body. The report made an important recommendation, which I hope the Minister will progress, to decentralise the HSE, not down to health board level but to regional bodies where the hospital groups and community health organisations would be merged. These merged entities would have one budget and the independence to deliver services in their respective region as the regions need these services. As such, we would not have the unwieldy centralisation that we have in the HSE at the moment. I hope the appointment of a HSE board is the start of that process.

We have seen how chopping and changing in our health management structures has inhibited real health reform. It has resulted in chaotic and fragmented health services. It allows for excellent and adequate care in some areas but unfortunately there are many areas in our health service that are extremely stressed and do not deliver optimum care. We have incoherent policies and a management structure that is almost impossible to navigate. We are all aware of the problems with our waiting lists and today we had 535 patients on trolleys, which in an average winter is now almost acceptable. Of course it is not acceptable. Trolleys are just a symptom of wider problems within our health service. We know trolley numbers will vary from one period of a year to another. If there is only one person on a trolley, it is an indication we have capacity issues with regard to staff and beds.

The present structure of the HSE is not fit for purpose. The management processes were put in place with 18 clinical directorates and a group of civil servants who must have had a conflict of interest in being civil servants and members of the board. The system became completely unwieldy and not fit for purpose. It was intended to be a temporary arrangement initiated by the then Minister, now Senator James Reilly, while he put some other structure in place. We were never quite sure what that structure would be. The replacement structures, which are not fit for purpose, are still there seven years later. That system has inhibited health reform, integration and structural reform in our health services.

One of the main difficulties in our health services at present is the lack of integration. People are in silos. They are in separate offices, directorates and divisions. They have separate budgets and do not speak to each other. As a consequence, much inefficiency and unmet need build up in the system. The HSE has had three directors general in the past eight months. We have failed to fill the position. We are now engaging in another interview process to try to find a candidate who has the skills and expertise to lead an organisation which has 135,000 people working for it. The person with the skills and managerial experience to fill that post will be very difficult to find. I believe there will have to be an extremely attractive package to attract somebody who can run a service like that. It would be money well spent because we waste so much money in our health service. We waste millions of euro. Look at what happened with the budget for the children's hospital. It has now increased by a factor of two or three, depending on what figures one believes. If it is going over budget by up to €1 billion, we must pay somebody an attractive salary to run an organisation to stop that kind of waste. It is very important that, apart from appointing a new HSE board, we have a director general of the HSE as soon as possible who has the skills and expertise to manage it. That person will be responsible to the board. As Deputy Connolly stated, it is very important because Tony O'Brien admitted he was reporting to himself. For several years he was reporting to himself. He had responsibility to the Minister but it is important we have a proper managerial structure in place.

The Scally report resulting from the cervical screening controversy highlighted in stark terms the deficiencies in accountability and transparency that exist in the health service. Deputy Connolly was quite right that accountability and transparency are absolutely essential when we constitute this new board. It has to be independent but it has to be answerable. It has to explain its decisions. When a political decision is made that affects our health service and which is incorrect or wrong, it has profound implications for the delivery of health services. We talk about clinical responsibility. If a doctor, nurse or health professional makes a mistake they are accountable to their professional bodies and if they are found to be negligent they will suffer the consequences. We make political and corporate decisions willy-nilly in our health service which has profound negative effects on it, yet nobody is held responsible. Nobody puts their hand up and says it was a wrong decision and if it had gone a different way many millions of euro could have been saved, the health of our patients could have been improved and lives could have been saved. Corporate decisions are extremely important and should not be underestimated.

Ciarán Devane has been appointed chair designate of the yet-to-be-constituted HSE board. He will have a very important task. First he will be part of the interview panel to appoint a new director general to the HSE. He will also have influence on the people who are appointed to the HSE board. It is very important the board is a slimmed down board from the previous board and that it has particular skills in change management. It is very important. When we look at the Sláintecare report and how it has to be implemented, we must have experience on the HSE board of change management and implementing reform.

The new HSE board will have important functions. It will have to ensure the HSE engages with the Sláintecare reform programme and engages with Laura Magahy, the director of the Sláintecare implementation office, to ensure that Sláintecare reforms are deeply embedded in HSE service plans year on year for the next ten years and for many years after that so that reforms are put in place to improve patient services and outcomes. The essence of a health service is to improve patient outcomes and deliver a service. I was impressed with the HSE service plan delivered at the end of December 2018 because for the first time it has embraced reform. References to Sláintecare are widely scattered throughout that report. There is an intention and recognition in the HSE that Sláintecare has to be delivered. There is a greater recognition within the HSE than there is within the Department of Health of the importance of delivering on Sláintecare.

The board must also build on accountability and transparency in managing and making decisions. I have said bad corporate decisions have a profound effect on population health. Deputy Connolly referred to the retirement of very senior people in 2012. The HSE lost a raft of experience as a result of a change in pension arrangements. It was not intended but it was a consequence of those pension arrangements. We lost a significant amount of corporate knowledge as a result. Look at the corporate decision on the children's hospital, the length of time it has taken to deliver it, the controversy over its location, the cost of construction and eventually the cost of commissioning which we learnt in the health committee this morning will cost €300 million. That moves the cost from €1.4 billion to €1.7 billion and we are four or five years away from the first child gaining access to that hospital. There are many corporate decisions that have profound effects on patients and unless those corporate decisions are correct, we will not have proper delivery of services.

The new board must also build trust in the health system in patients. Unfortunately, there are many patients who do not trust the health service. They do not trust the HSE to deliver the service. Many patients are afraid to go into hospital now because of previous experiences or those of friends or family or because of listening to the news every day which reports there are 400, 500 or 600 people on trolleys. We have to build trust, not only in patients but also in staff. If we do not build trust in staff who feel fulfilled going to work and have job satisfaction, we will lose them and we are losing them. We are losing our graduate doctors, nurses and therapists who are going to other systems that function properly and give them job satisfaction. We must build trust. We should not underestimate the importance of morale. I remember when the Minister for Health took up the position, I told him in the Dáil that the first thing he could do which would not cost a penny was to try to improve the morale of the staff working in the health service.

Unfortunately, I do not think he has been able to manage to do that yet.

The new board must also build a relationship with the Department of Health. Looking at the interactions between the Department of Health and the HSE in the Committee on Health over the past two and a half years, there is palpable tension between them. Perhaps that is a good tension but there is a lot of negativity while there is not a proper process of engagement between the Department and the HSE. There often tends to be a blame game. There needs to be an honest and forthright interaction between the two to support new and innovative models of care. The models of care we have at the moment are not working because there is a lack of integration and because our health system is built on models of care that were okay 40 or 50 years ago. Health technology and health management have moved on but the structures underpinning our health service are still the same. New, innovative models of care mean integration between primary and secondary care and vast improvements in communication between those looking after people in the community and those looking after people in our hospital services. They are in silos and separate and there is very little communication.

One of the major problems is that we do not have an IT system or ICT to manage a modern health service. We do not have a unique patient identifier or an electronic patient record. Those two things are the drivers of health reform. Not only will they deliver efficiencies but they will also give us data. We cannot manage a health system if we do not have data. Data are king. Data are money. If we do not have real-time data on what is happening within the health service, our planning will not be optimal. The new board will have to concentrate on all those things.

The board must drive integration of our hospital services between the community and consultant and hospital-led services. It must expand bed capacity. There is no point in denying that we have a huge deficit in bed capacity. The bed capacity review suggested that if we engage in full-bodied health reform where we change structures and change our models of care, we will still need 2,600 beds over the next ten years. If we do not engage in health reform and keep doing what we are doing while expecting to get a better result by magic, we are going to need 8,000 beds. What chance have we of getting 2,600 beds, let alone 8,000? One of the major reforms also recommended by Sláintecare is that we have elective-only hospitals where patients coming in for elective care are not continually being displaced by people coming up from casualty. There is a whole range of things that the HSE board needs to concentrate on and it is a huge task.

We must make Ireland a magnet for health staff. We are repelling our graduates, nurses, doctors and therapists. They are going away to health services that work, that can give them job satisfaction and job progression. It is not all about money. It is about being allowed to deliver a level of care to the maximum of their training. It is about their will to provide a health service, and there is great will in our graduates. They want to deliver a health service but they find, having trained in the service here, that they cannot see light at the end of the tunnel. They have low morale and they go elsewhere where they get better job satisfaction.

I hope this new board will achieve all of the items Deputy Connolly and I have mentioned. Unless we innovate, change and reform, this health service is going to continue to deteriorate.

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