The regional future of the health service

The HSE will undergo a radical reorganisation from next month with the implementation of the six health regions. David Lynch reports

Addressing healthcare staff in late January, HSE Chief Executive Officer Mr Bernard Gloster said the imminent move to six new health regions “represents a considerable change to our organisational structures”. 

However, Mr Gloster added “structural change is not the main goal” of the reform.

“The idea behind reorganising our structures is to ensure that people experience just one health service, providing whatever care they need at the right time and in the right place.”

The six regional executive officers (REOs) have been appointed and the regions will go live on a gradual basis, beginning next month (see panel).

Speaking at the 20th National Health Summit held in Croke Park, Dublin on 7 February, HSE Chief Operations Officer Mr Damien McCallion said the regions were about “trying to push back out and devolve” responsibility across the country. He recognised that the HSE “is often criticised for being overly centralised”.

Reflecting on the old health board system, Mr McCallion said those boards “were probably completely devolved, but didn’t have some of that glue that was needed around policies and strategies so that you could get consistency across the country”.

The new regions, which will commence on 1 March, will be “gradually introduced” until September, he outlined.

Consultants

The reorganisation will be felt across the entire healthcare system and all specialties. 

Consultant Oncologist Dr Grainne O’Kane addressed last month’s National Health Summit on the issue of cancer care (see p8).

Dr O’Kane, who is Director of the Cancer Clinical Trials Unit, Trinity St James’s Cancer Institute, later spoke to the Medical Independent (MI) about the structural changes.

“I’m worried that the new regional health areas could further fragment the system, to be honest,” Dr O’Kane said. “I worry about the governance; I worry about leadership. The point I would make is that I want people in the hospitals knowing what’s going on…. I do not want the regional health authorities with leaders sitting in offices and not being ‘on the ground’.” She warned that such a scenario could negatively impact the delivery of care in this country.

Dr O’Kane said that greater digital transformation in healthcare was needed to allow better patient information flow across regions and hospitals and between hospital consultants and GPs.

“There should be no reason why we don’t have an integrated electronic healthcare system in this country,” she told MI. “I know from many GP colleagues, that they do not understand what is happening with their patients [in hospitals]. They are not getting the letter, sometimes they never get letters… then they are trying to figure it out by talking to people themselves.”

Similar concerns have been voiced by other hospital consultants. Last October, IHCA President Prof Robert Landers told MI it made sense to align hospital and community services “into six coherent organisations”.

However, Prof Landers added that the regionalisation plan did not devolve authority at a local level to a sufficient degree.

“And our concern is that this is just another layer of administration within the health service that removes decision-making away from the frontline to a higher level and will impact and hinder efficient and quick decision-making.”

EDs

Emergency departments (EDs) across the country will be impacted by the new regionalisation programme. The Irish Association for Emergency Medicine (IAEM) President Prof Conor Deasy said the regions could have a positive impact if they help eliminate delayed transfers of care by providing a more “seamless flow of patients” from acute hospitals to community services, rehabilitation facilities, and nursing homes. He told MI that this would create additional bed capacity in hospitals.

 “We should not expect, however, that bed capacity issues will be solved without building beds, be they acute hospital beds in the form of ICU and single room ward beds, rehabilitation beds, and long-term care beds.”

 Prof Deasy, Professor of Emergency Medicine at University College Cork and Clinical Director of Emergency and Acute Care at Cork University Hospital, said “there is simply no avoiding this and we should get on and do it; our population need and deserve this.”

Prof Deasy added that regions are seen as an enabler to shift healthcare provision to the community setting. Therefore, providing primary care with “the tools and incentives to deliver unscheduled care would reduce the ever-increasing volumes of patients” who attend EDs.

“It is very important that the required monitoring systems are in place to measure the impact of this investment.” 

According to Prof Deasy, a “key selling point” of the regions “is less bureaucracy and greater agility”.

“…. What works in Cork may not be relevant in Dublin so local fixes and solutions can be more easily facilitated and funded through more localised governance structures delegated to the regions…. This potentially could be a more empowering and rewarding system to be part of,” according to the IAEM President.

GPs

GPs will be keenly observing how the new structures will alter the relationship between the primary and acute sectors.

It is “too early to say” what effect the regional structure will have on general practice, Prof Tom O’Dowd, GP and Professor of Public Health and Primary Care, Trinity College Dublin, told MI.

“It’s a funny thing to say, but it depends what you believe is more important – anatomy or physiology. The anatomy refers to the structure of things and the physiology is the interactions. What I find most beneficial are the interactions with the people in the HSE who I know myself and have solved problems for me in the past, that has worked very well.

“And I would not like to see so much organisation going on that it interfered with those relationships – that the anatomy interfered with the physiology, so to speak.”

Prof O’Dowd was speaking to this newspaper at the Health Summit.

“It does seem that in many ways that we are going back to the older system, going back to having health boards, or at least a version of the health board system. Which actually was quite good a system and was a responsive system generally,” added Prof O’Dowd. “In general practice, I suppose, we tend to take less interest in the structure of the system. And that perhaps is a problem for us; we perhaps need to be more active in it.”   

Optimistic

Also speaking to MI at the conference, former Deputy Chief Medical Officer at the Department of Health, Dr Ronan Glynn, said there will always be “challenges with transformational change”.

Dr Glynn, who is now Partner and Health Sector Lead at EY Ireland, said he believed the health regions will reframe the perception of health service provision.

He added that this reframing should lead to people seeing healthcare as “a continuum across community and acute settings”.

“Then maybe to re-imagine the concept of clinical teams and multidisciplinary work so that teams aren’t just working within the traditional four walls of a hospital, or in the traditional community setting, but instead we have better collaborations across different settings,” he told MI. 

Regarding the new regions, he said: “I think you have to be optimistic.”  

Dr Glynn’s former public health colleagues within the HSE also envision possible opportunities in the coming changes.

A spokesperson for the Irish Society of Specialists in Public Health Medicine (ISSPHM) told MI that the area directors of public health will sit on the area senior management teams as the regions form.

“This presents an opportunity to influence the agenda, bringing the public health focus and dimension to the protection and promotion of health, prevention of disease, and healthcare delivery,” said the spokesperson.

“Working within the new areas can allow for population-based planning and a real focus on equity and the needs of the regional population and health services.” 

Risks

However, the ISSPHM spokesperson warned that this optimistic scenario is not “a given”. 

“There is also the risk that the population focus will be sidelined, with a continued prioritisation of a hospital-centric approach, with acute hospital services receiving the majority of funding and focus,” the spokesperson said.

They added that senior public health leadership is also crucial at national level and that the National Director of Public Health should sit on the executive management team of the HSE. “This is currently not the case.”

The Society believes the new regions “must put a greater focus and investment” into prevention and community resources and developing community-based models of care “rather than just moving acute services into the community to reduce the burden on hospitals”.

The ISSPHM spokesperson added prevention is not merely about promoting changes in risk behaviours, but also ensuring that the broader social determinants of health are addressed.

“Therefore, the new health regions must work hand-in-hand with local county councils, schools, and communities, etc, to ensure that these social determinants are optimised for their regional populations.”

The spokesperson said significant progress in the national digital infrastructure was also needed.

“A unique health identifier, a public health case management system, an immunisation information system, etc, are all critical in ensuring a more coordinated and efficient public health service delivery at a regional level and would also ensure better data to evaluate and improve the services we deliver.”