Published: Irish Medical Times, 12 August 2005

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When Professor Drumm takes the tiller at the HSE next Monday, he will inherit a health service that is ailing badly and sorely in need of a cure.

Health will always hog the headlines, often for all the wrong reasons, but invariably because no amount of additional resources has ever been enough to fix a service that is complex in nature and structure, and resistant and resilient in the face of all attempts to reform it.

Throughout 2004, there was an almost obsessive fixation, within the health services at least, about the new structures that were to replace the old health boards.

By January 1, it was abundantly clear that the only thing likely to change that fast was the name over the door. Delays in recruiting the chief executive officer, allied to the fact that a number of the most senior management posts still remain unfilled on a permanent basis, have reinforced a widespread perception that the reform programme is drifting perilously close to the rocks.

Expectations will be high of the man with an €11 billion budget and full executive responsibility for a service that now accounts for one-quarter of all Government spending. Inevitably he will become a lightning rod for public, political and professional criticism when things go wrong.

Reform programme

But he will also have the goodwill of the many stakeholders as he sets out a vision of what needs to be put right and attempts to steer through a reform programme that is long overdue.

Dr Drumm will have at least five years to effect meaningful, lasting change within the public health system, and to reach a genuine accommodation with a private healthcare sector playing with all the confidence of a team with the wind at its back. Indeed, his legacy may well depend on two critical factors.

First, on whether he can forge a true partnership between public and private providers that is person-centred, service-oriented and quality-driven.

Second, the extent to which he can help to bring about a sea-change in people’s expectations of the health services, and their attitudes to personal health and well-being.

Building a HSE that supports and drives change, rather than getting in the way of it, will be a major cultural and organisational challenge.

After all the working parties, steering groups and task forces of recent years, the pressure is now on to deliver.

GPs have been offered a major package aimed at resolving long-running contractual grievances and introducing a doctor-only medical card. With a €93 million deal covering the major issues likely to be accepted by the participating doctors, the scene is being set for a big shake-up in the way primary care is organised, delivered and financed in the near future.

More consultants on way

With 1,000 new hospital beds and more consultants and support staff also on the way, some easing of the capacity constraints that continue to plague the acute sector should be expected. Steps are needed to strengthen and reorganise the whole gamut of community-based health supports, particularly for older people, those with mental health problems and people with a disability.

Painting a picture of an improved health service has always been the easy part. However, as a visit to any art exhibition will prove, people find it much more difficult to agree what are the best brushstrokes, much less whether the price of the finished canvas is worth paying.

Health reform has always been problematic, not least because people are reluctant to trade with what they have already for something that may be better, but ultimately so costly as to elude them altogether.

It looks now as though this circle is about to be squared, at least in the acute setting. The Government’s decision to move 1,000 private beds out of public hospitals and into stand-alone private developments on public hospital campuses should boost the amount of work the public sector is able to do, assuming, of course, that the necessary additional resources follow the “new” freed-up public beds.

Although the idea of moving private beds out of public hospitals has been around for a number of years, it is only now getting the push at political level.

Stretched to its full potential, the plan will introduce a more competitive, entrepreneurial dynamic into acute hospital care, leaving the public sector free to buy certain services from the private operators and, perhaps, selling other services based on its own distinctive competencies.

Assuming that the bed plan isn’t scuttled by the planning laws, it will be a giant step towards the target of restoring 3,000 beds to the acute services.

With 900 extra public beds planned to be available by the end of this year, at least 409 beds on stream, or coming through, in the biggest of the newly built private hospitals, and 1,000 beds to be released in existing public hospitals, the original target should eventually be at least three-quarters achieved, even if the original timetable won’t be met.

The HSE has a critical part to play in getting public and private providers to co-operate more closely so as to avoid under- or over-provision of services.

Facilities like breast screening, currently unavailable to women in the south and west of Ireland, have been offered by the new state-of-the-art Galway Clinic, but turned down by HSE West, which intends to provide these services sometime in 2007.

In July, this newspaper also reported that the radiotherapy services task force had not factored the provision of six new linear accelerators by private operators into its calculations, and may thus have ignored the potential for real co-operation between the public and private sectors in the provision of radiotherapy services.

All of this underlines the need for a coherent vision of how the value of the public-private mix can be maximised, and for service provision to be grounded on clinical need and practical co-operation rather than ideological conviction.

Hospitals are, however, only one part of the picture, albeit a very important part. Ultimately, the battle for overall health and well-being would be won or lost in the primary care setting. Almost three years after the pilot projects were announced, however, the rollout of the strategy and the teams has stalled.

Some progress has been made, but, for the most part, the original vision of a dynamic primary care sector – dealing with health problems at the lowest levels of complexity, integrating and coordinating services and professionals across boundaries, and supporting self- and family care – has been lost amid a welter of recrimination and accusations that there is neither the will nor the way to effect real change.

Unless some creative thinking is applied to the fundamental issues, particularly up-front financing and long-range resource planning, the primary-care strategy will remain a pipe dream.

And that will serve nobody’s interest – least of all the needs of patients and clients, the vast majority of whom care not one whit who provides services, so long as they’re available when needed.

It is surely only a matter of time before the kind of incentives that have been given to the acute sector are offered to the private operators in the primary care sector – perhaps led by a new entrepreneurial class of General Practitioners – in order to kick-start the strategy.

With a vigorous, well-resourced primary care system built on networks a professional expertise and research as much as geographical needs, and buoyed up with referral pathways into secondary and tertiary care, the way should be clear to treat many more people much more effectively in the right setting, thereby helping to make the most of additional capacity in the system as a whole.

Fears that the public sector is retreating and giving private providers free reign are undoubtedly real but not necessarily well-founded.

Something has to prime the pump and get the investment flowing, but there is no absolute requirement for that something to be the State.

Neither is it clear that the private operators will trigger a race to the bottom, or that the public sector always offers a higher standard of service and care and can be achieved by non-State providers.

The HSE can ensure a level playing field by developing clear, comprehensive and binding frameworks for service provision, which are rigorously enforced on private and public operators by an inspectorate with real teeth, to ensure a smooth patient or client journey.

It is now almost a quarter of a century since Professor William Ouchi wrote a highly influential book, Theory Z, in which he showed how successful US firms imported and applied Japanese methods to their own cultures and needs.

With features like job security, consensus-based decision-making, slow evaluation and promotion, and moderately specialised careers, the successful firms are, in fact, quite similar in character to our HSE.

Where they differ is on the level of responsibility to give to the individual, and in the informal controls they use to ensure that goals are achieved.

If Dr Drumm and his team could sow the seeds for this kind of culture, which rewards initiative and experimentation, it would give a huge boost to the task of managing a modern health care system and knowledge workforce to the best of its potential.

Remarkable change

Ireland’s health services are set for a period of remarkable change and reform. Neither will be accomplished easily, and people will inevitably stumble along the way.

Persuading a knowledge workforce to experiment in an environment that is averse to risk-taking will be one of the greatest challenges. But there needs to be space for failure as well as success.

As Mahatma Gandhi once remarked: “Freedom is not worth having if it does not include the freedom to make mistakes.”