Brian Edwards CBE
Professor of Healthcare Development
The Irish Government published two health reform papers recently that herald major changes in their health system. The first was a product of the Treasury and argued that the system was inefficient and ill coordinated. It was providing neither patients nor taxpayers with value for money. Doctors neither paid regard to nor understood the financial consequences of their day-to-day practice. The problem in Ireland, it argued, was no longer one of inadequate investment but of how well the existing investment was deployed. The second paper looked at structures.
In systems that are highly politicised such as that in Ireland commercial comparisons are unsatisfactory. Voters are the all powerful customers and they usually resist change if it diminishes local services, even if the planned changes produce a more effective and efficient outcome for patients. The normal economic laws do not apply. The new Irish plan puts some distance between local politics and health. All the existing Health Boards are to be swept away and replaced by a single executive agency with a statutory base, which will run services through a network of local offices. It will have an independent Chair appointed by Ministers and its own Chief Executive. All public hospitals will be managed by the new agency but the system will remain pluralistic with independent and private sector hospitals significantly engaged in providing services. The Ministry for Health and Children will step back from operational matters while remaining still accountable for the overall system. Separating out policy and operations has been tried before and rarely works, as politicians are eventually drawn back into problem areas. Plans that are technically sound but politically unpopular are unlikely to be approved, but that is the downside of democracy, and for some represents an important check on the professionals who have to persuade communities that their plans are sensible.
What a new single structure will do is present an opportunity for clinical networks to develop, with services being managed on the basis of the patient’s journey rather than institutional balance sheets. In this way it is hoped there might be a stronger connection between the many individual decisions made by clinical staff and their economic consequences. A big shift to shared backroom services is expected to produce substantial economies.
An important feature of the Irish plan is the intention to renegotiate the hospital specialists’ contract, to ban or control private practice. A complete ban is almost certainly unworkable, as most other European countries have discovered. Clear rules and open book accounting usually provide a more satisfactory answer. Primary care, which is currently weak, will be strengthened probably by the injection of nonmedical health professionals rather than many more doctors who are in short supply. A decision will have to be made about the expansion of medical schools but, if made, will only produce longer-term benefits.
The weakest feature of the plans is the extended time period over which they are to be introduced. Three years is too long for radical organisational change. The uncertainty it generates will cause major problems of continuity and morale. The changes need to be made decisively if the benefits are to outweigh the dangers. Overall these plans go with the grain of modern health practice and many other countries will be observing the results with a keen interest. Health is proving to be a difficult industry to modernise.