The decision by Minister for Public Expenditure Jack Chambers to strip four regional health boards of their fiscal autonomy has a key similarity with the move by Minister for Justice Jim O’Callaghan to cut the fees paid to legal aid solicitors appearing in the criminal courts. Both decisions have had – or soon will have – unintended and politically difficult consequences.
In O’Callaghan’s case, this has manifested in the disruption seen in the courts, which – for example – saw 12 teenagers appear in the Children’s Court recently without legal representation.
The consequences of the Minister for Public Expenditure’s decision to take away control of day to day spending at four of the six regions (West and North West, South West, Dublin and South East, Dublin and Midlands) will unfold in time. It is likely to be a variation of the conundrum that has faced every politician who ever tried to trim a health budget: what services do you want to cut?
Trying to control the health budget is part of a drive by Chambers to slow the rise in State spending. He had little choice but to try and bring some discipline to health spending, which is again going way over budget this year. But demands on the service will only increase and the search for efficiencies and savings will only get so far. Hard decisions will now have to made. It is an open question as to whether the Health Service Executive – which has now taken the fiscal reins at the four regions – will be any more effective in budget management.
The decision two years ago to devolve day to day budget decisions to the six health regions was based on the view that regional executives were best placed to decide how services are organised and could allocate budgets to meet local needs.
This may well be true, but the reorganisation manifestly did not – and perhaps could not – constitute any sort of solution to the ever-increasing pressure on the health service because of a growing but at the same time ageing population, medical inflation, new therapies and wage demands.
These factors are at the root of the lack of control over employment and spending that led to the intervention by Chambers. Looking at successive overruns, the key question is whether the Coalition has been setting unrealistic budgets, or the health service is unable to manage its resources. Or, perhaps, a bit of both.
Choices will now have to made about which services are trimmed and which patients are to see their treatment delayed or cancelled. The axe may be wielded by the HSE in the first instance but the trail of blame will now lead via the Minister for Health Jennifer Carroll MacNeill to the door of the Minister for Public Expenditure.
History shows how hard it is to increase productivity and improve delivery in the health service and how politically toxic this can become.