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Divided opinions on regional divide

Paul Mulholland examines communications between the Department of Public Expenditure and Reform (DPER) and the Department of Health in relation to the development of regional integrated care organisations, which show the DPER’s concerns about the proposal

orrespondence exclusively obtained by the Medical Independent (MI) through Freedom of Information law shows tensions between the Department of Public Expenditure and Reform (DPER) and the Department of Health in the run-up to the announcement on the new regional division of the health service.

Only two months before the plan was announced, in correspondence with Dr Colm O’Reardon (PhD), Deputy Secretary General, Policy and Strategy Division, Department of Health, on the regional integrated care organisations (RICOs) proposal, Mr Ronnie Downes, Assistant Secretary, Central Expenditure Policy, DPER, stated on 30 May the DPER had “serious reservations about pressing ahead with this initiative in its current state of readiness”.

Mr Downes wrote that “more time is needed to work” on the proposal before asking the Government “to initiate such a substantive reform”.

One of the major issues raised, according to Mr Downes, was the financial position of the HSE.

“It is unclear to us how this proposed approach will help to address this challenge,” according to Mr Downes.

“Indeed, there is a clear risk that providing potentially more autonomy to Hospital Groups might further exacerbate the problem. Addressing this fundamental issue is a prerequisite to any reform, in this Dept’s view.”

Mr Downes also stated that it was unclear whether there has been “sufficient reflection on previous efforts to reform the way in which we deliver health services so that we avoid repeating the mistakes of the past”.

“In our previous comments, we indicated that a comparison exercise on how the establishment of regional integrated care organisations compared with previous and current structures would be an important element of the background analysis,” according to the DPER Assistant Secretary.

Mr Downes stated there was also a need for a mapping exercise in advance of any reform so as to understand how the existing services in the proposed new regions would lead to efficient allocation of resources.

“Finally, and perhaps most importantly, in order for any reform to succeed, there needs to be clear ownership of the issue,” according to Mr Downes.

“As acknowledged in the draft memo, there have been substantive reforms in the governance structure in the HSE in recent weeks. It takes time for these sort of reforms to bed-down and take shape and for the new board and CEO to understand the different dynamics, risk and determine their overall priorities. The draft memo does not make reference to any consultation with the new board and CEO, or to their views on the relative priority and state of readiness of the proposed RICO approach.”

As a result of these issues, DPER’s view was that it would be “premature” to press ahead with the RICO proposal in its current form, and that a more “deliberate approach” would allow for all relevant parties, such as the new CEO and board of the HSE, to form a view on how this initiative can support their reform agenda.

“It may be, for example, that a proposal which sketches out a broad ‘roadmap’ of integrated regional care provision, to be formulated, piloted and adapted over time and building upon existing promising initiatives in this space, would stand a more realistic chance of forming the basis for an agreed approach which meets the interests of all stakeholders involved, including this Department,” according to Mr Downes.

‘Alarm’ at HSE’s finances

As revealed in the previous issue of MI, the DPER refused to support a draft memo for Government on the creation of RICOs due to the discovery that the HSE’s financial position was worse than expected.

In an e-mail on 19 June, Mr Downes referred to a recent meeting between DPER and the Department of Health, during which the subject of RICOs was discussed.

“[W]e… agreed that any such substantive decision on the part of Government would need to be taken on the basis of a fully-developed and tested business case which, realistically, would involve a period of intensive preparatory work, which we in DPER would do our part to support,” according to Mr Downes.

“We also agreed that, in the interests of helping to foster a sense of direction as part of the Sláintecare Implementation Strategy, there may nevertheless be merit in bringing a memo to Government to inform them of the work-to-date in developing geographical templates for future RICOs… ”

However, Mr Downes said the DPER’s position regarding the memo changed as a result of the HSE’s financial performance in the first quarter of the year, which was worse than expected.

“I have to say that in light of the alarming news regarding health sector over-spending in Q1 2019 — which now appears to be far worse than previously indicated — the narrow space for even such a memo may now have evaporated, and we will not be in a position to support such a memo in advance of an urgent engagement on how the over-riding priority of cost management is being addressed,” according to Mr Downes.

In response, on 20 June, Dr O’Reardon stated the Department of Health fully shares concern over the emerging financial position in the HSE.

“Nonetheless, it is clear that fundamental reform of the HSE is necessary, both to deliver better and integrated patient care, but also to improve the financial and employment control environment, to enhance performance management and to improve accountability,” according to Dr O’Reardon.

“To this end, this Department believes that it is important to move ahead with the reform agenda.”

Following the recent meeting, Dr O’Reardon said  a number of changes had been made to the draft memo, to more clearly reflect the work that is required before the Government should commit itself to implementing the RICO model.

“We have also had a useful discussion with your team about the proposed boundaries,” according to Dr O’Reardon.

“These have been designed following an exhaustive statistical analysis of hospital discharge data on the one hand, while on the community care side, building on the boundaries of the proposed community health networks, which were designed following a lengthy study of service usage in community settings as part of the CHO [community healthcare organisation] report. Establishing clarity on what the boundaries of a regionalised structure would be is essential if we are to move ahead with developing a business case, as described in the draft memo. To move ahead without taking this step would risk a lack of clarity about what is being proposed. At the same time, publishing a map does not commit the Government to moving ahead with this reform agenda, and the revised memo makes this clear.”

On 21 June, Mr Downes noted Dr O’Reardon’s acknowledgement of the emerging financial situation in the health sector, and also the need for reform to address underlying problems in relation to budgetary control.

He said the DPER’s main concern is that any such proposals should be shaped so as to support this “imperative of sound budgetary management, and that we must avoid the risk of premature action which might in fact exacerbate the situation”.

Mr Downes stated that the budgetary control problems in the HSE would be the subject of a Ministerial bilateral meeting.

Regional boundaries

However, regarding the geographical boundaries of the new regions, he wrote that the Vote section in the DPER has “not been persuaded that the underlying analysis adequately addresses the central issues regarding how hospital service provision should be configured in alignment with primary care services”.

“I note also that fundamental questions regarding the optimal configuration of the existing hospital distribution, towards a rational alignment with the proposed integrated regionalised model, do not feature in the analysis at this point,” according to Mr Downes.

“While ultimately it is a matter for your Department to bring forward your considered proposals on this policy issue, against the background of the statistical and other analysis that you point to, I should say that it may prove difficult to prepare a persuasive business case unless these issues are comprehensively addressed in this context. It is against this background, and with an eye to these significant concerns and risks, that we will consider and prepare our observations on the specific proposals that your Department is bringing forward.”

Business case

A note from Ms Laura Casey from the Department of Health to Mr Downes on the revised memo was sent on 21 June. According to the note, the memo was revised to take account of recent discussions with the DPER and also feedback from the Department of the Taoiseach.

Following this, on 12 July, Dr O’Reardon e-mailed Mr Downes in advance of the memo coming before Government. Again, he stated the text of the memo relating to regionalisation incorporates a number of changes based on the comments of the DPER.

“In particular, it makes clear that the Government is not being asked to make an irreversible decision on setting up RICOs, but rather is endorsing the development of a business case, which will be brought back to Government in due course,” according to Dr O’Reardon.

“The decision sought also includes endorsement of a set of boundaries for the RICOs which will form the basis of the business case. These boundaries have been developed following extremely detailed and lengthy analysis of patient flows, and are based on a set of criteria as set out in the memo. Nonetheless, as the memo makes clear, further refinement of these boundaries will be possible, where justified by evidence-based analysis arising during the course of the business case preparation, prior to being made definitive as legislative geographical boundaries.”

With regard to DPER’s original suggested language (which referred to “provisional” geographies), Dr O’Reardon wrote that the Department of Health believes this would be “inappropriate for inclusion in the decision sought and that a more nuanced reference to ‘administrative’ geographies is sufficient in that part of the memo.”

“It is important not to give a signal to health service providers that the boundaries can be ignored or changed other than on the basis of clear evidence of patient benefit,” according to Dr O’Reardon.

“The quality assurance referred to in the memo will be carried out by the Department of Health in line with and as part of the evidence-based analysis supporting the detailed business case and full policy proposals.”

The proposal to divide the health service into six regions was announced on 17 July 2019 by Government.

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