1. Planning in the Irish Health Services Reconciling External Legitimacy and Organisational Implementation Vivienne Byers, Dublin Institute of Technology EHMA Conference June 2008

2. Context – Need for Planning Irish spending on health has gone from 15 per cent below the OECD average to 17 per cent above in the period 1997-2003 (Source: Department of Health & Children 2005) However, spending of 7.1% GDP lowest of EU15 (source: OECD 2006) Life expectancy 2 nd lowest in EU15 after Portugal (source: OECD 2006). After a decade of exceptional economic growth. Debate over the value for money that the health service Recent public service review

3. Overview – Planning in Health Past as prologue Strategic Management Initiative Health Care Strategies 1994 & 2001 The 1996 Health (Amendment) Act No 3 and its successor 2004 Health Act Strategic Planning Service Planning

4. Research Focus Planning, strategic management and accountability…. National Health Strategy Possible difficulties/ Propositions: Legislation – the control mechanism Organisational capacity

5. Planning in Health Care The Street Level Public Organisation (SLPO) (McKevitt 1998, Byers and McKevitt 2007) Government: General Legislation Resource Allocation, Organizational Structure, Performance Measurement. Professions: ‘Rules of the Game’ Client-Citizen; Street Level Public Organisation (SLPO): Health Board/HSE area B C A

6. Case Study Organizations A comparative study 2004-2005 This presentation reports on part of a wider study Phase 1: Examination at Health Board/Regional Level in Ireland Observation & Analysis of documents/archives

7. Some Findings A number of key issues emerged  Health professionals  Managers Two of the themes identified will be used to underpin the key propositions established at the outset  Determination of Service levels and needs  Stakeholder Representation

8. Determination of Service levels and needs The service planning legislation is meant to facilitate strategic planning;  Health professionals – priorities not based on needs analysis but on historically based budgets  Frustration, powerlessness, lack of IT support to gather data  Managers – Clean sheet reviews not feasible, control process politically influenced. Needs analysis not seen as priority. Disconnection of Management from Operating Core  Control

9. Stakeholder Representation The service planning legislation is meant to facilitate strategic planning through devolved decision making;  Health professionals – Stakeholders in the process? Relations with government at an all time low. In establishing ‘rules of the game’ some had withdrawn from the process. ‘Real planning’ exercises.  Managers – Difficulty in engaging health professionals in the process. In many cases ‘planning can be done well enough without them’. Again, disconnection of Management from Operating Core  Organisational Capacity to plan?

10. SLPO Model – Needs Analysis Government: General Legislation Resource Allocation, Organisational Structure, Performance Measurement. Street Level Public Organisation (SLPO): Health Board/HSE area B Control System – Look at legislation for guidance as to the service planning process. Core theme of needs analysis identified would assist in strategically driven resource allocation in line with principles of the national Health Strategy. This had not occurred because these principles were not explicit in the legislation (results in a break or point of tension at B)

11. SLPO Model – Stakeholders Divisions between management and health professionals stark SP used as a control mechanism rather than an inclusive planning process (see Point A) Street Level Public Organisation (SLPO): Health Board/HSE area Government: General Legislation Resource Allocation, Organizational Structure, Performance Measurement. Professions: ‘Rules of the Game’ Client-Citizen; C A Point C: Thus, Professions are often blamed for weaknesses in the system

12. Conclusion - SLPO Model  Nexus of relationships is not acknowledged  Therefore, the health professional and citizen-client not involved in the process  This results in lack of needs based planning.  Reliance on the service planning legislation means it remains a budgetary exercise Inconsistency  Legislation has purely control focus  Organisational capacity to change is limited partly due to breakdown in relationships Real Planning Real Planning – What business are we in?  Budget control?OR  Provision of services for the citizen?