Reform is now possible, but will the Government follow through, asks Maev-Ann Wren?
How will patients benefit from more streamlined administration of the health service? If the reform programme announced yesterday simply achieves efficient processing of letters of refusal to applicants for medical cards, who gains?
Let us be clear. This "health service reform programme" is not the same thing as a reform of the health service - not the kind of reform which would make medical care available to many more low-income families. What the Government has announced is a reorganisation of administrative structures. Even were yesterday's reforms implemented overnight, there would be no additional hospital beds, nor doctors, nor nurses, no unravelling of the two-tier system, and not one extra medical card.
Which is not to say that more streamlined administration and better accountability should be dismissed. Or that reconfiguring 32 out of the 58 health agencies is a bad idea. Or that the time had not come to find a way to take necessary decisions about ceasing to offer sub-standard care in sub-standard hospitals. The Government has announced a potentially significant step on the path to reform. The removal of local councillors' veto on the reorganisation of regional hospital services is a major change which could unlock the political logjam that has impeded the development of hospital care since the 1960s.
But many questions remain. If now we are to have a more centralised executive power in health, what decisions will it execute, and who will take those decisions? And will patients benefit?
There are some things which the reform programme will not do. It will not significantly reduce the number of administrators. The Government and the authors of yesterday's reports do not perceive that as the problem of the health service. It will not necessarily save any money on administration, although it may. And it will not remove politics from health, nor should it.
The new Health Service Executive (HSE) will be answerable to the Minister for Health, who in turn remains accountable to the Oireachtas. Its annual service plan will be agreed with the Department of Health. High on its agenda will be the implementation of the report of the Hanly taskforce on medical staffing, to be published in July. That report will make yesterday's programme look tame. Abolishing health boards is a much less challenging exercise than determining which hospitals will cease to have casualty departments or offer obstetrical care and which will become the well-endowed regional centres of excellence, status symbols for their county and providers of local employment.
The new administrative structures ensure that local councillors will no longer have a voice in such decisions, but who will? The Minister for Health was less than clear in his answer at yesterday's press briefing. It would seem that some critical details have yet to be teased out.
When the Hanly report is published, it will make precise recommendations for hospital services in two pilot regions and establish broad general principles for services in the rest of the State. Will the National Hospitals Office (NHO) then decide how those principles should be applied without ministerial input? This seems highly unlikely, undesirable indeed. For without the input of local councillors, the Minister becomes the voice of democracy in the health service.
Reading between the lines it would seem that the Minister and his Department will have to sign off on any national plan for hospital reorganisation. So the potential will remain for politicians to veto the advice of expert groups, which they may do for the best or the worst of motives. The theory guiding these reforms is that the Minister will be driven by the national interest, whereas local councillors were motivated by defence of local services, at the expense of the development of regional centres of excellence.
Department of Health planners apparently hope that yesterday's reform will make it possible for them and their Minister to agree a national plan which will allow the development of such centres of excellence and which will be implemented by the NHO. For patients this would mean perhaps that they must travel further when they require specialised care or suffer major trauma, but will be travelling in the knowledge that their journey will increase their chance of survival. As Prof Niall O'Higgins has testified in relation to breast cancer care, women who are treated in larger centres have a 15 to 20 per cent better chance of survival after five years.
An unpublished draft of the Hanly report argues that "the importance of treating seriously ill or injured patients in a centre that is fully equipped to meet their need cannot be overstated". In answer to the fears of local people about seriously ill patients being asked to travel further for care, the report argues that many life-saving measures in emergencies are not affected by the immediate proximity of a hospital.
Two-thirds of deaths from heart attacks happened before the patient reached hospital, while three of the most effective immediate responses - use of a defibrillator, cardiac resuscitation, and "clot-busting" drugs - could be delivered by emergency ambulance personnel. Similarly, after a serious accident, early action to maintain an airway and reduce bleeding could be administered by ambulance personnel, while the next most important prerequisite for survival is to be treated in a hospital offering comprehensive skills and facilities - the regional hospital.
Smaller hospitals would treat less serious complaints, offer day surgery by teams coming from the regional hospital and allow GPs to admit patients who require nursing and remain under their care.
These arguments are the sub-text to yesterday's reorganisation package. The abolition of the elected health boards is not driven by a perception that they have been spendthrift or corrupt, but by a belief that only at national level is it possible to take the tough decisions about the location of hospital services, which implementation of the Hanly report will require. Yet there is many a slip between cup and lip and although the Government promises early establishment of these new executive bodies, the next crucial step, their unleashing to implement a true programme of reform, is by no means a foregone conclusion.
And, in the meantime, what about investment in health care? Have the proponents of "value for money" proved their case that health spending need not rise because of all the potential efficiency gains? With Charlie McCreevy sitting beside him, Michéal Martin, who recently supported higher taxation to fund health, smiled ever so slightly yesterday as the Tánaiste was forced to defend her belief in low taxes.
Even after the publication of the Brennan report which the Minister for Finance had commissioned, McCreevy advanced no explanation of how he envisaged that this package of reforms would obviate the need for greater investment in health. Despite its recommendations on financial systems, the Brennan report had not supplied him with such an explanation. That was another sub-text to yesterday's announcements.
While defending low taxes, the Tánaiste yesterday conceded that health would require "considerable resources" in the future. The measures which will change patients' experience of the health service - ready access in need, an end to discrimination between classes of patient, enough beds, clinics, staff - require sustained investment and altogether more ambitious reforms than the package announced yesterday.
Maev-Ann Wren's book on the crisis in healthcare, Unhealthy State - Anatomy of a Sick Society - has just been published (New Island, €17.99)