It says something that the resignation of an unelected official yesterday made the level of news that it did, in Ireland. Paul Reid was never chosen by the voters to run the health system, and, if our democracy works as it is supposed to, his resignation should change absolutely nothing. Decisions about how resources are allocated, how the system is managed, and so forth, are rightly made by the Minister for Health. That is the nature of a public system – that the public, ultimately, have control over it.
But that is not how Ireland works in practice. In practice, the Chief Executive Officer of the HSE is a highly paid role – Reid leaves on a salary exceeding €400,000 – because one of the responsibilities of the job is to take the blame. It suits politicians perfectly, though they will never admit it, to have massive public resentment about the pay packet of the head of the HSE. Such anger provokes you to say things like “it’s a disgrace that man getting paid that much money and the health service in a crisis” rather than, say “it’s a disgrace what this Government has done with the health service”. The absurd salary is almost the point of the exercise. It’s designed to draw your attention.
One wonders, looking at Mr. Reid’s tenure, what its highlights were. As with many public service careers, the highlights are not measured by what he achieved, but by what he “got us through”. He was the head of the HSE during the covid pandemic. No doubt, if he seeks future employment elsewhere, that will be line one on the CV: “lead Ireland’s health service through the unprecedented challenge of the covid 19 pandemic”. Such CVs tend always to focus on things that coincided with a time in office, rather than substantive achievements. They say things like “oversaw structural reform of pay and conditions” rather than provide any measurable indicator of success.
And what are those successes, in Reid’s case?
As he leaves the HSE, he leaves it with a bigger budget. In his time in office, from 2019 to today, the health service has added additional billions to its annual budget. That additional money has not been matched by masses of additional beds, or frontline staff, or a reduction in waiting lists. In actual fact, waiting lists have increased, with almost half the population now waiting on some kind of health procedure, and some of them waiting years.
None of this is to have a go at Reid, necessarily. Just to say that in an ideal world, his departure would provide an opportune time to look again at the whole structure, and prioritisation, of the public sector, and indeed for the role of the HSE.
The organisation is called the Health Service Executive. That, right at the start, is a clue to its unsuitability and the way it mitigates against public accountability. The true “executive” of the health service is Stephen Donnelly, and the true board of directors are the voters. We have, for some reason, allowed that function to be outsourced to unelected officials.
What’s more, the lack of control over the health service is felt more locally, than nationally. In my lifetime, this country had regional health boards, governed by elected councillors and officials, who oversaw regional service delivery. That system had its flaws, but we often overlook the benefits: Local democracy, for one thing, ensured that there was a focus on delivering the services people needed to the places that they were needed. That has been replaced by the nebulous concept of having a “national strategy” for everything, which in practice has meant the gutting of local services across the country and the idea that everything should be centered in “centres of excellence”, which is a name that occasionally betrays overconfidence in the hospitals that are so designated.
Are we really happier with the new system, with all its attendant hour-long ambulance drives to a local Accident and Emergency, and those Accident and Emergency units being overcrowded and inefficient? Were the emergency units in places like Monaghan and Navan and so on really such a bad idea?
Everything now is geared towards the national: A national maternity hospital and a national children’s hospital, to cite just two examples, both of which are destined to become multi-billion euro boondoggles. As recently as 1995, people in my home county gave birth in the maternity unit in Monaghan General Hospital. That has been closed – but has the maternal mortality rate really improved significantly? Not especially, mainly because it was very good to begin with.
It would be interesting to see the full outlay, over its lifetime, of the HSE on “reports” and “strategy consultations” and “management reviews”. One suspects the figure runs into the tens of millions. There is a space for those things, but very often, in the lifetime of the HSE, reports have become a kind of undemocratic substitute for the kind of simple common sense that the health boards usually came up with instinctively. The whole thing is symptomatic of the country’s embrace of a kind of technocratic, expert-led system of Government, where “a populist” is the worst thing you can be, and where the experts know better how to deliver a service than the people who use the service, and the people who ran it for generations.
The end result is this massive managerial superstructure that sits atop the health service, overseen by one of the best paid civil servants in the western world, who gets paid, in part, to take the blame for the dissatisfaction his organisation produces.
The HSE is nothing more than conclusive evidence that not all change is progress. It should go. It should have gone years ago.