Vested interests come in for a battering, writes Dr Muiris Houston, Medical Correspondent.
The Brennan Commission Report is a hard-hitting one. As Professor Niamh Brennan admits herself, it pushes the envelope regarding its terms of reference. And while it stops short of making recommendations beyond its remit, the report contains some stark messages.
It shares with the Prospectus report a desire to see the creation of a new Health Service Executive to run the system on a day-to-day basis. This would take the Department of Health away from the "firefighting" it is continually drawn into and allow it the space to evaluate spending and set priorities.
It differs in not specifically seeking a reduction in health board numbers.
But the Brennan Commission has attached significant riders to avoid promoting an additional layer of bureaucracy.
It wants the Eastern Regional Health Authority (ERHA) subsumed into the new executive and it clearly calls for a consolidation of the 64 independent agencies which have evolved in the health sector over the past 30 years. Crucially, it states that the management of the health service be "explicitly devolved" to the head of the new agency.
The Brennan Commission report also outlines the revised governance arrangements which the new executive and the health boards need to put in place.
Defining corporate governance as the "way in which an organisation is directed and controlled so as to achieve its organisational goals, and to deliver accountability, transparency and probity", it is the part of the report most identified with Prof Brennan herself.
As a forensic accountant, with a professional track-record in the area of corporate governance, the need to shake up what she sees as an indefensible "laissez-faire" attitude to management runs right through the document.
Hospital consultants take quite a battering in this report. Although acknowledging the sanctity of clinical autonomy, the commission clearly feels that the concept has been allowed to govern management decisions to an excessive degree.
And so the consultants' common contract comes in for severe criticism, with Prof Brennan labelling it shocking and unbelievable.
The recommendation that all new consultant posts be public practice only will be fiercely resisted, even by the younger consultants who are open to some change.
They will not resist the commission's call for monitoring of their activities and hours of duty, but they will baulk at having to choose between private or public practice.
Many train for years in the United States, where many patients are treated in the same facilities regardless of who is picking up the tab. In fact, such a severe division of patients is neither Boston or Berlin, to draw on a popular analogy. If it is implemented, international health policy analysts will have to add Dublin as a way point on this particular transatlantic map.
GPs and pharmacists don't escape either. Family doctors will be expected to furnish annual reports to their local health executive. And for those who overspend their budgets, this amount will be "netted off" at the beginning of the next funding tranche.
Pharmacists can expect changes to what Brennan sees as anomalies between General Medical Scheme (GMS) and drug refund scheme reimbursements. Cosy deals between wholesalers and pharmacists, which the commission says adds further profit, will be examined.
Prof Brennan has told The Irish Times of her fear that this report will be implemented in a piece-meal manner.
In this she has the NHS experience in Britain to back her up. The latest report on Gordon Brown's largesse and reform package point to a failure to go the whole way in implementing change for that not dissimilar monolithic structure.