The six new health regions, which are now being implemented across the country, are an integral part of creating access to essential health and social care as close as possible to home and central to delivering Sláintecare reforms.
The rationale for the health regions is for everyone in Ireland to get better, and more seamless healthcare by integrating the current silos of hospital and community care; by allocating resources based on population health need (not just historical budgets); and to facilitate clinical and corporate governance and accountability.
Since March the six health regions have been operating under new regional executive officers who report to the HSE chief executive Bernard Gloster. From September the previous structures of Community Health Organisations and Hospital Groups will be “stood down” when the health regions become the main architecture for delivering health and social care with a plan for more localised integrated healthcare areas.
Research that my team and I carried out at Trinity College Dublin on the governance of the design and implementation of the new health regions in 2018-2023 found deficiencies in five aspects of governance – transparency, accountability, participation, integrity and (policy) capacity. Performance was particularly poor in terms of accountability, transparency and integrity.
The research found a complicated and changing accountability structure for Sláintecare and the regions over the five-year period. The biggest changes were the resignations of senior Sláintecare leadership in September 2021 and the establishment of a Sláintecare Programme Board with the Minister designating both the HSE chief executive and secretary general of the health department responsible for its implementation. While ultimately health system reform is the responsibility of the secretary general of the Department of Health reporting to the Minister for Health, accountability for implementing and realising change and policy is less clear and more contentious.
The research revealed inherent conflicts and accountability deficiencies between the Department of Health and HSE in the policy process. Such conflict has its origins in the poorly formulated foundation of the HSE 20 years ago, persisting up to 2023 contributing to a “conflict at the centre” in the design and implementation of the regions. Differences in whether the regions should progress and a lack of agreed vision on them resulted in little progress in the early years of planned implementation. Covid-19 and the HSE cyberattack got in the way, in terms of political capital and will to implement the reforms, as well as the capacity of the system to execute change whilst coping with a pandemic and then a malicious attack on its IT systems.
The research also found some improved coherence at the top between the HSE and the health department since the establishment of the Sláintecare Programme Board and a regional advisory board, the appointment of a senior HSE national director to lead the regional implementation and a new HSE chief executive in March 2023.
The Department of Public Expenditure and Reform (DPER) emerges from the research as a key player that makes many of the essential health decisions that are outside the health governance structure. As one senior health leader pointed out, DPER has de facto decision-making power without any formal accountability to the health system.
Similarly, the accountability structure for the new health regions detailed in the 2022 Department of Health Business Case and the July 2023 health regions implementation plan is not clear-cut. These documents specify that the regions will be administrative divisions of the HSE (rather than separate legal entities) with budget autonomy. Despite full implementation from September, it is still not clear what budgets will go to the regions and what will remain at the centre.
There is an absence of clarity on whether this move is about reforming the entire health system or just the HSE – much of the information communicated to date is HSE-specific. While the rationale for the reform is for better integration for all components of the health system, which include many private and non-Government providers such as GPs, nursing homes, pharmacists, community and voluntary organisations, their involvement in the new regions to date has been minimal.
In terms of transparency, the research found a huge deficit in publicly available information on the design and implementation of the regions. This was true for those in senior health system decision-making posts. There have been some recent improvements in communicating plans, yet much of this information remains internal.
While there seems to be system capacity to develop policy, there are significant inadequacies in terms of implementation capacity. The role of consultancy firms in the health regions policy process emerged as a key finding with many aspects of the regional reform being contracted out to third parties. The use of private consultancy is expensive (raising value-for-money issues) and a cause and consequence of the absence of agreed vision, leadership and implementation capacity within the system to deliver reform. Those working in the system believe this has negative impacts due to the loss of institutional knowledge but also buy-in from the people responsible for delivering the change. We know that early, frequent participation of key stakeholders means reforms are more likely to be implemented effectively. This has been largely absent from the regional reform process up to now.
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A central finding underpinning the research is the importance of trust. Improving transparency, accountability, integrity and participation of all stakeholders in health systems governance and reform as well as investing in implementation capacity will increase trust. Trust by the public that the health system is there to meet their needs in a timely, effective, efficient manner. Trust between those on the front line and health systems leaders. Trust between the health system and broarder political leaders and the Department of Public Expenditure and Reform.
Trust is the fuel of good governance. The new health regions are important for everyone’s health and vital to ensuring timely access to quality care.
There is still time for our political and health system leaders to learn from lessons on the health regions policy process and to get their governance right.
Sara Burke is associate professor and director of the Centre for Health Policy and Management at Trinity College Dublin and co-author of The role of governance in shaping health system reform: a case study of the design and implementation of new health regions in Ireland, 2018–2023
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