More than structures – the introduction of Regional Health Areas in Ireland
Dr Niamh Lennox-Chhugani, Chief Executive, International Foundation for Integrated Care.
The Department of Health in Ireland published the long-awaited business case for the establishment of Regional Health Areas (RHAs) this week as Cabinet approved the case. The Chief Executive of the Health Service Executive (HSE) has said that these bodies will be operational by the first quarter of 2024.
We shared our thoughts on the opportunities for RHAs in our paper Sláintecare – Delivering the promise of universal person-centred care in Ireland published in October 2021. These focused on:
- Creating the infra-structure for the analysis and synthesis of regional data to inform population health planning and feedback on results and impact;
- Providing systems leadership and governance through which new alliances of collaboration across sectors can be built and maintained;
- Creating the supporting infra-structure and governance for innovation with a focus on digital solutions through industry and research collaborations moving beyond traditional procurement models;
- Providing the information to support workforce planning and the specialist expertise for workforce development as new models scale and evolve.
The business case quotes a recent OECD paper (1) that through systematic review, concluded that there is a ‘happy medium’ in the centralisation – decentralisation debate leading to lower spending and better health outcomes. Ireland is currently one of the most centralised systems in the OECD.
I reflected on what this means in practice in different systems across the world when presenting at the Health Summit in February 2022. Watch the pre-recording here.
The option that has been approved by the Cabinet is the HSE-Local option. This was one of three options considered, one of which was the ‘no-change’ option and the other, the Separation model. It is worth reading the document published by the Department of Health. It is concise and well written. The case for change in terms of person-centred integrated care and population health and well-being is clearly set out. There is little detail on implementation but more has been promised to follow.
Taking an international lessons learnt lens to the HSE-Local model, I would observe that this option seems to have chosen mainly because it would be least disruptive to the existing system and would not require any change to current legislation unlike the alternative Separation model. This does not make it the wrong decision, but neither does it make it the right one. We have seen from the experience of Finland and England that introducing primary legislation to restructure a health and care system to enable integration is fraught with challenge. But in the end, removal of structural barriers to integration are inevitable. In the case of both England and Finland, legislation has been introduced to create the conditions at regional and municipality levels for integration.
Looking at the other evaluation criteria that were used, both options were reported to have similar evaluation scores(2) for population-based funding, service planning and integrated service delivery. Given the media reporting of the Cabinet decision(3) and the focus on devolved authority and regional autonomy, either this is not the case or the interpretation of what is possible under the HSE-Local option has been flawed. My reading of the HSE-Local option (remember it is the least disruptive because there is little if any change to legal accountabilities) is that RHAs will be subject to HSE Centre direction with limited leeway for regional autonomy in designing local models of care or developing new alliances with the voluntary sector, both key pillars of integrated care.
One of the real strengths of the regional model in Denmark and the new regional system being introduced in New Zealand, is the flexibility that regions have to analyse, plan and deliver services based on local population needs in the context of community representation. In New Zealand, the regional bodies are accountable up the National Health NZ and down to District Health Boards and take predominantly a coordination role for providers across health and care. In Denmark, the regions runs hospitals and commission other service from municipalities based on regional population health needs assessment and priorities. The Danish Health Authority at the centre is responsible for setting and assuring standards.
Devolving authority to the regional level is a critical design principle in integrated care. The move to decentralise decision-making in health and care in Ireland is evidence-based by the business case’s own assertion. But it is likely that what is currently approved may not go far enough to deliver on the stated ambition to facilitate comprehensive integrated, person-led, community-first health and social care through the alignment of acute and community-based services. This includes aligning corporate and clinical governance, within a strong national context, and aims to enable better performance assessment of the health service. RHAs will support population based service planning, the integration of community and acute care, and will empower local decision-making (pg13). Perhaps there is an incremental plan, we will see when the detailed plan is published.
This business case is a step forward in the plans for a regional model of health and care integration in Ireland. There is much to be done in preparing the implementation plans. My recommendation would be to focus on building capacity and capability that is foundational to integrated care at regional level as a starting point, namely population health planning, systems leadership, innovation and workforce development.
1 Dougherty, S., Lorenzoni, L., Marino, A. et al. The impact of decentralisation on the performance of health care systems: a non-linear relationship. Eur J Health Econ (2021). https://doi.org/10.1007/s10198-021-01390-1
2 Evaluation criteria were (1) corporate governance, (2) clinical governance, (3) population based funding, service planning, integrated service delivery, (4) feasibility of implementation which includes cost of transition and legislative changes.