Irish health reform – ‘incremental change in the fullness of time’….
From the Medical Independent on 25 September 2014
Just eight weeks after the new Minister, Leo Varadkar, was appointed to health, his Department officials released the briefing documents prepared for him. These reveal the vastness of the Government’s aspirations for health reform, as well as their failure to deliver on all of the Government’s key health commitments.
Briefing documents previously prepared for James Reilly and Frances FitzGerald (when children was still part of the Department in 2011) were also released, three months after they took up the posts. This was equally long, although a more polished document with colour graphs and greater coherency.
Enda Kenny was extremely critical of the briefing prepared by health officials this time around — he is not interested in large volumes of text on why health reforms cannot be achieved, he just wants action on achieving explicitly-stated Government health policy. And this is what one would expect from any half-decent leader.
However, it is equally understandable that any documents prepared by health officials would be resistant to extensive change. I worked on a temporary contract for two-and-a-half years in the Department of Health from 1997 to 1999. During my time there, the junior administrative staff were threatening to go on strike and were terribly worried about the prospect of striking. There was a gag going around the Department at the time as to what their protest chant would be. It went as follows:
“What do we want?”
“When do we want it?”
“In the fullness of time!”
In a way, this sums up the very nature of civil servants and health policy in Ireland, which are inherently conservative and traditionally, change has only ever come about in an incremental way. Therefore it is to be expected that the extent of reform as proposed by this Government would be resisted.
There are other rational explanations for the Department’s resistance to James Reilly’s reforms. There were over 87 health commitments in the 2011 Programme for Government. It was never going to be possible to make all of them happen in the timeframe as originally envisaged. There was also incoherency between the reforms and the distinct absence of a plan on how and when they would be implemented.
For example, in 2011 the Government committed that a “system of Universal Health Insurance (UHI) will be introduced by 2016, with the legislative and organisational groundwork complete by 2016”.
Subsequent policy statements — Future Health in 2012 and the White Paper on UHI in 2014 — pushed this out to 2019. The briefing documents stick to the 2019 commitment but statements made by Minister Varadkar since taking up office happily acknowledge that these are not plausible. This in effect shelves the plan to hand over billions of public money to private insurance companies. The majority, probably including health department officials, never thought was a good idea.
The Programme for Government stated that the HSE would cease to exist. Future Health specified a range of complex reorganisations and new bodies that would need to replace them. The briefing document provides an organigram of what this might look like, which must have been designed to confuse.
Interestingly, it is with this reform that there is most resistance to in the briefing document. It describes the abolition of the HSE and its replacement with an unquantified number of quangos as “unworkable”. While no-one thinks the HSE is a perfect organisation, it is the biggest employer in the country, providing essential care day-in, day-out to millions of Irish citizens. One cannot propose its dissolution (which was meant to come into effect this year) without clarity and structures on what might be put in its place. Plus we know from international experience and the establishment of the HSE, that major reorganisation such as that proposed causes major disruption and takes at least three-to-five years to achieve.
The briefing sticks to the Government commitment of universal free GP care by 2016. Again, we know that it is extremely unlikely that free GP care will be delivered to anyone other than under-sixes and over 70-year-olds by the next election.
That said, if universal free GP care is introduced and the commitment to a single-tier health service is delivered, anytime in the next five-to-10 years, history might be kinder than the briefing documents to James Reilly’s reform legacy.
And only time will tell us if Government’s aspirations for health reform will ever be achieved.