Review will require candour from all involved
Ivan Cooper, Director of Public Policy
The establishment of a review group to inquire into the current role and status of voluntary organisations in the operation of health and social services is a very welcome development. It is understood that the review will be looking at the issues which arise in connection with the provision of services to the public through voluntary organisations and that it will make recommendations on how the relationship between voluntary organisations and the State in the arena of health and social services should evolve in the future. So it’s a very important review for the future of the voluntary sector.
Given that a very large quantum of our health and social services are delivered by voluntary organisations – the HSE provided voluntary organisations over €3.7Bn in 2016 involving 1,900 grants of less than €100k with 570 organisations receiving over €100k – the findings and recommendations of the review may have profound implications for our health and social services and for the work of voluntary organisations for decades to come.
And that impact will likely have knock-on-effects on the practice of other funding departments (such as social protection, community and rural affairs, and children) through precedent-setting as many departments and agencies outsource large parts of their service delivery to voluntary organisations.
The review takes place in the context of general reform of our health services (reference the Slaintecare Report) and debates about the the fitness for purpose of the HSE (reference Tony O’Briens contribution at the MacGill Summer School and his Sunday Business Post article of July 23rd) and also potentially ties into current debates about the increased uses of commissioning processes and competitive tendering; the appropriateness of the funding mix for public services and the sufficiency of Exchequer allocations; the privatisation of services; and even whether Ireland’s tax-take is sufficient to cover the cost of public services.
It seems to me that an effective review has to consider some key questions:
- Our health and social care system must meet people’s needs and be focussed on maximising positive health and social outcomes – so we need to be clear from the off about what optimal health and social outcomes look like for people, and then determine what services are required, and how they are to be organised to deliver these outcomes.
- In working out what optimal services should look like, we need to consider the implications for the budgets of such services, and the adequacy of the current funding-model, comprising as it does a mix of exchequer funds, service-user contributions, earned-income from provider’s activities and fundraised income. Should core public services be depending on contributions from service-providing organisations? What are the cost implications of the way that services are currently administered and managed?
- Is the financial and non-financial added-value that voluntary service providers contribute to public services sufficiently appreciated, or is it a taken-for-granted subsidy to the cost to the state of delivering services? What precisely is this “added-value” and should it have a role to play in core health and social-service provision?
- Is there any evidence that services would be delivered more effectively under a more centralised approach? What can be done to better integrate services and ensure accountability, without micromanaging organisations that provide those services? Can the positives of the current approach be adjusted to harness the flexibility, responsiveness and innovation of autonomous voluntary service-providers by working more strategically with the state? How could service planning be approached more strategically with this objective in mind?
We can see from the above issues that the review of the role of voluntary organisations in service provision cannot take place in isolation – it must take place as part of, and with reference to general reform processes to better orient healthcare around people’s needs.
And if the review is to be positive and productive, we need to surface an uncomfortable truth – there are many interests (most overt, but some covert) in our current social and healthcare system, and we need to make these explicit and acknowledge them if the review is to avoid becoming a battleground. I’ll have a bit to say about interests below.
Another important requirement for all stakeholders participating in the review will be to banish the word “private” from the discussion: all the organisations that will be affected by the review are charitable entities that are effectively public in nature – and that means all the funds under the control of the voluntary boards concerned are public funds – irrespective of where they come from. There are no private funds under the control of charitable trustees – the public has a right to understand how all funds, irrespective of where they came from, are being used. But that recognition needs to be balanced by an acknowledgement by the state that it values, and does not take as a given the effort that service-providing organisations make to raise additional funds to cover exchequer-funding deficits in meeting the cost of services.
Many additional questions are immediately sparked by these initial considerations, and this suggests the complexity of the terrain the review is going to have to navigate to be successful. In approaching this article, it seems to me that a stakeholder analysis is a good way to understand the issues and interests that will need to be acknowledged and reconciled. So let’s take a look at some of these stakeholder groups.
People and services
First and foremost comes meeting people’s needs. People should have access to the services they need when they need them. And the quantity and quality of services should be consistent throughout the country. Given that there is effectively infinite demand for health and social services, there is always going to be a compromise necessary in relation to the quantum and quality of services available, but both should at least be consistent and at a level that is regarded as fair and which generally satisfies.
From current waiting lists, geographic-area black spots, and HIQA quality reports, I think it can reasonably be said that we still have a long way to go to optimise services from the perspective of people who require them. The Slaintecare Report states that “The best health outcomes and value for money can be achieved by re-orientating the model of care towards primary and community care” and that “everyone in Ireland should have access to public health, health promotion, diagnostics, treatment and care when needed in the appropriate setting as close as possible to their home, within a reasonable period of time, with little if any charge at the point of access”. Given the key role played by voluntary organisations in health and social care provision, the question for the review from the perspective of service-users seems to me be how can the current service-mix be reorganised and funded aso people have access to care when needed in the appropriate setting as close as possible to their home, within a reasonable period of time, with little if any charge at the point of access?
The Department of Health
The Department of Health and the Minister for Health have statutory responsibility for governing the health service – and that means for ensuring that the health and well-being of people are maximised. Simple as that.
They also have a collective responsibility (as part of Government) for determining the level of public funds to be allocated to providing for health and social well-being, and for ensuring value for money in the delivery of services. So the Minister and the Department need to firstly set the review strategically in the context of the Slaintecare Review and the Healthy Ireland Framework which envisions an Ireland where “everyone can enjoy physical and mental health and well-being to their full potential; where well-being is valued and supported at every level of society and is everyone’s responsibility”. Secondly, the Minister needs to guide the review towards identifying the optimal way of providing (and funding) services that take into account and seeks to build on, the huge contribution currently made by voluntary organisations.
In my view, a consideration of the role played by voluntary organisations will be incomplete and suboptimal if it doesn’t also consider the role that statutory service providers also play in the health and social services mix. It is the strengths and weaknesses of both modes of service delivery –statutory and voluntary – that need to be considered in the round if an optimal outcome for people is to be arrived at. In addition, service-users don’t exist in a vacuum – all of us are members of communities that shape and support our health and social well-being status – so that community-dimension to public health also needs to be considered in the mix.
It seems to me that the simple question for the Minister and the Department is: “in the context of the Slaintecare Report and the Healthy Ireland Framework how can we best organise the current service-mix of statutory and voluntary providers to achieve optimal health and wellbeing outcomes for people?”
On the face of it, the HSE’s objective is the same as the Minister’s with an operational focus bring greater coherence to how health and social services are designed and delivered. But we need to acknowledge that the HSE’s interest is somewhat different from that of the Minister and the Department. Some of what follows is uncomfortable – but we need to surface it if the review is to be open and honest. The HSE is the executive arm of the health system – it’s primarily concerned with service-delivery. Of course, the HSE is also responsible for supporting and advising the Minister and the Department in relation to health and social care policy, and we can often conflate the Minister, the department and the HSE into one. But the HSEs interests are not identical with the Minister and the Department. The HSE is a corporate agency, and as agency theory tells us, all agents have their own (often unconscious) self-interest to advance – distinct from the interests of those that employ them.
The HSE is also a very big, and very powerful agent. The biggest and the most powerful by far in fact, in this whole policy space. It holds most of the funding cards and is overwhelmingly powerful in relation to the organisations it funds. And it has its own corporate interest in the context of the review. I need to be clear that I am speaking about HSE Corporate (not any individuals – even at the top) and the bureaucracy it constitutes, rather than the tens of thousands of people who work hard, selflessly and in good faith every day to meet people’s needs. How does this self-interest manifest?
It partly manifests in the way that services are delivered through contractual agreements between the HSE and voluntary organisations whereby the HSE minimises its own exposure to the risks inherent in services while maximising its ultimate control over those services through using Service Level Agreements that place responsibility (for what are essentially public services) solely on the boards of outsourced providers.
With this in mind, some might say that an unofficial-and-covert goal for HSE Corporate (and entirely rational in the light of agency theory) going into the review is to shift as much risk in services as possible onto external providers while simultaneously maximising their control. But you likely won’t hear anyone else saying this. And remember, I am not suggesting that this is a conscious objective of the HSE or of ANY HSE staff – more a subconscious, agency-theory related motivation that we need to take into account. I believe that the review will do itself a disservice if it’s not at least conscious of this unstated, self-interested objective. There is also a fairly overt policy objective on the part of the HSE to encourage smaller organisations to merge into bigger units to make the coordination and management of services easier. Is bigger necessarily better when it comes to public services?
The official and overt question for the HSE is the same as for the Minister and the Department: “in the context of the Slaintecare Report and the Healthy Ireland Framework how can we best organise the current service-mix of statutory and voluntary providers to achieve optimal health and wellbeing outcomes for people?”
Voluntary boards of service-providing voluntary organisations
Similar to the agency theory argument that applies to the HSE, many boards of voluntary service providers that are funded largely by the state find themselves governing very complicated services for which they bear personal responsibility while simultaneously overseeing highly skilled and experienced managers immersed in, and on top of, the detail of those services.
Such boards experience a twofold power imbalance: they face the power of the HSE itself in the form of the compliance requirements demanded by the Service Level Agreement that accompanies HSE funds, and they oversee much more experienced managers on whose advice they depend for the integrity of their decision making. In other words, we have boards that on paper are autonomous and responsible for everything that happens on their watch – but who in reality, may have relatively little power and ability to independently determine their own course.
This is an unsatisfactory state of affairs in terms of good governance practice and contributes to a perpetuation of a culture of “insufficiently accountable managerialism” (agency theory again) that many would argue bedevils our health services when they function poorly. Resolving this unsatisfactory reality where some boards feel they have “all the responsibility but none of the power” must be one of the key objectives of the review.
Additionally, the consequences for organisations of years of budgetary austerity and increasing compliance and regulatory requirements are raising a whole series of issues such as the ability of boards to cope with the high governance standards now (rightly) expected; the ability of organisations to retain skilled staff (most organisations are still obliged to operate pay-freezes); and the challenge of delivering quality services with inadequate budgets. All of that said, we need to acknowledge that the boards of voluntary organisations also have their own self-interest in this review.
The self-interested (agency theory again) question for the board of voluntary service providers is: How can we maximise our autonomy and independence (vis a vis the HSE, and in some cases our own management teams) while advancing the values that we embody in our services, in a context where (for many) the vast majority of the funds controlled are provided by the state?
The objective question for boards should be “is the current role we play optimising outcomes for people and the communities they are a part of, and if not, how can we change our contribution – and what supports do we need to succeed in that?
Paid employees of service-providing organisations
The HSE funds voluntary health and social service organisations under two sections of the Health Act – Section 38 and Section 39. The vast majority of organisations (over 700) are funded under section 39 – where the state agrees to fund the work of organisations because that work happens to be in line with state policy. The forty-three Section 38 organisations are, however, funded for a different reason: if they weren’t providing their services the state would be obliged to provide those services directly itself. The state faces no obligation to provide funding for the Section 39 organisations – it chooses to do so – yet many arguably “essential” health and social services are in fact provided by Section 39 organisations under this (arguably relatively insecure) arrangement.
Staff in Section 38 organisations are thus regarded as public servants (because they are providing essential services that the state would have to provide otherwise) and they benefit from public-service terms and conditions and salary scales. But staff in Section 39 organisations are simply regarded as employees of third-party suppliers. This has led to a circumstance where such staff are delivering (arguably) unacknowledged core public health and social services, but effectively constitute a second-tier labour force, doing the same work as their Section 38 counterparts, but on lower pay and inferior terms and conditions. Is this the way we should be treating people who are delivering core public services? And if not, what can be done to regularise the situation? Or is someone going to seriously say that these services, relied on by people and families the length and breadth of the country, are really not “essential public services”? These are the questions that need to be resolved it seems to me.
The public interest / the taxpayer/value for money
First of all – we are all taxpayers! Everyone pays VAT – so this perspective is really about the public interest, not just the interest of the squeezed middle or the payer of income tax. According to recent data Ireland has the second highest health spending ratio in the OECD. Yet nobody could argue that we have optimal outcomes for that spend. So there is undoubtedly a question here as to whether the way that we have organised our health and social services is delivering value for money for all of us as citizens and taxpayers.
But as we can see from the above analysis, there are many different aspects that need to be taken into account in evaluating the effectiveness of the current approach. While value-for-money considerations are important, the review should focus equally on the effectiveness of the current approach in maintaining community health and well-being; in engaging people in their health and social services; and in maximising flexibility, responsiveness, innovation, participation and accountability in a coherent, integrated and strategically clear context.
The proposed review presents a great opportunity to build on the strengths of the contribution that voluntary service providing organisations can make while addressing the strategic weaknesses of the approach. We need to ensure that the review does not descend into a tug of war over who controls what: all stakeholders share a common interest in delivering best outcomes for people, and the focus should be maintained on that common objective.
There is a healthy inter-dependency between the state and voluntary providers when they work well together, and it is that that we should be seeking to enhance. It used to be called partnership working, and that is what we should aim at rather than spend time arguing for independence and autonomy while seeking to dominate and control each other. Ensuring accountability needs to balanced with a respect for autonomy.
I believe the proposed review provides a great opportunity to achieve these objectives if we enter the discussion with open minds – acknowledging some of the less-than-noble, but inevitably human, motivations that might otherwise distort the outcome. We have to make sure the review doesn’t become a battle of self-interest – and that applies to all participants, voluntary and statutory.
The Wheel has a great deal to say about all of these matters on behalf of our members – so watch this space – and we look forward to engaging constructively with the expected review when it commences its work.