Structural Reform Programme
The overall direction for health reform was set in the Programme for Government, Future Health as well as other policy documents. Commitments which have emanated and evolved from the Programme for Government include: abolition of the HSE and a decentralisation of decision making; establishment of a Healthcare Commissioning Agency, independent hospital trusts and new primary and social care structures; competing insurers to buy services for patients; and a purchaser provider split (P/P split).
Future Health provides more detail on how the reforms will be implemented and describes a phased approach to be applied to the structural reforms as summarised below. Given the complexity and breadth of the issues to be addressed, considerable preparatory work must be undertaken in advance of the development of the legislative proposals.
Phase 1: This phase of the transition was aimed at: (i) introducing revised governance and management structures in the HSE; (ii) the establishment on an administrative basis of seven hospital groups; (iii) revising the structures for delivering primary, social and mental health care following a review of the Integrated Service Areas; and (iv) establishment of the new Child and Family Agency. There was also a commitment to fund the HSE through the Vote of the Office of the Minister for Health which required the introduction of legislation.
Phase 2: Phase two of the structural reforms envisages the eventual dissolution of the HSE and introduction of a formal purchaser /provider split in the health sector. It should be noted that the system will remain entirely tax funded during this phase. Future Health proposes under this phase: (i) establishment of a Healthcare Commissioning Agency (HCA); (ii) establishment of a national agency to promote health and well-being; (iii) the evolution of hospital groups to trusts; and (iv) establishment of new primary and social care structures. The structural reform programme is focused on delivering this phase of the proposed reforms.
Phase 3: The final phase of structural reform envisaged in Future Health involves the move to a combination of universal health insurance funding for acute hospital and certain primary care services, with general taxation funding for other services including social care services such as disability and long-term care.
Minister Varadkar has concluded that the targeted date of 2019 for implementation of Universal Health Insurance is not achievable. The Minister stated his intention to instead concentrate on immediate priorities including the operationalising of the hospital groups, embedding of Activity Based Funding (ABF) in the health services, as well as a focus on the development of GP and primary care services and the new Community Healthcare Organisations. Minister Varadkar also indicated that the HSE would need to remain in place until these reforms have been properly bedded down.
Progress to date
Good progress has been made on a number of aspects of structural reform to date as outlined below:
- The revised governance and management arrangements are operational in the HSE following the enactment of the Health Service Executive (Governance) Act 2013;
- A Child and Family Agency (Túsla) has been established;
- Hospital Groups have been established. Chairpersons are in place for six of the hospital groups, with the role being filled on an interim basis pending appointment of a new Chair to the Saolta University Healthcare Group. All Group CEO’s are also in place (including an acting CEO in the Saolta University Healthcare Group).
- Creation of the new Community Healthcare Organisations has commenced with the appointment of their respective Chief Officers;
- Following 2014 legislation, the new HSE Vote arrangements commenced in January 2015;
- Implementation of Activity Based Funding (ABF) commenced January 2014;
- The Healthcare Pricing Office (HPO) was established on an administrative basis in the HSE in January 2014: and
- A HSE division led by a National Director was established to implement shared services in the health system.