A PRESCRIPTION FOR CHANGE

11. Accountability and Reform

Accountability and Reform

Multi-Annual Funding

Funding and reform must go hand-in-hand. Sinn Féin would implement multi-annual funding frameworks to provide funding certainty and improve accountability. We would first apply these to improvement strategies, infrastructure delivery, digital transformation, and medicines, with a view to widening application to current expenditure programmes. These would control spending by limiting use of funds to specified new developments.

Multi-annual funding frameworks will enable more effective public service delivery once Health Regions have assessed their population-based care and capacity needs. We would mandate each health region to develop a population-based care and capacity plan to inform strategic investment and workforce planning. This would enable multi-annual funding for services to invest where they need it most, and drive community care and digital investments which are suited to different population needs.

Sinn Féin Will:

icon_check iconImplement multi-annual funding frameworks for improvement strategies, infrastructure delivery, digital transformation, and medicines

icon_check iconDevelop population-based budgets

icon_check iconControl funding on the basis of reform delivery, rewarding best practice and progress against waiting time targets

Efficiency & Savings

No funding plan would be credible without a substantial savings target. Sinn Féin would set a savings and efficiencies target of at least €1 billion, equating to 4% of the current health budget.

We would set a target of €200 million a year in savings for five years. In the context of significant additional investment, new technology, and more sustainable care systems, we believe these are at the lower end of what can be achieved. More than €450 million is paid out through the State Claims Agency in health-related claims, and this has more than doubled in recent years. Long waiting times on lists and in emergency departments is a contributing factor.

A Sinn Féin Government would seek to achieve the maximum savings possible but for the purposes of our funding plan, we are setting a minimum target of €1 billion to part-fund our additional measures. This is a necessary target to ensure the sustainability of the health budget into the future.

Health spending has increased by 51% since 2019. It is widely recognised that much of the increased spending has not been allocated efficiently, and there is widespread waste across the health service. Additional costs are being added to the health service by legacy constraints: the HSE is chronically burdened by paper, pen, and postage-based record systems; acute hospitals are the primary but most expensive method of providing care; and long waiting lists lead to more complex care needs, further driving costs. Wide-ranging measures, from improved primary care, a focus on prevention, and swifter action on waiting lists, are needed to improve the efficiency of health spending, in addition to direct cost-cutting measures.

More than €2 billion has been spent on agency staff by the HSE in the last 5 years. Annual spending has risen from €330 million in 2018 to €647 million in 2023. There is a significant premium estimated for agency hours, approximately 20%, which could be saved by direct employment. Spending on consultancy services, excluding IT consultancy, amounted to €44.7 million in 2020, and rose to €92.25 million in 2022. The cost of these contracts is estimated at three times higher than if the people were employed directly. More than €380 million was spent by the HSE outside of procurement rules in just three years from 2020 to 2023. Hundreds of millions are being incurred annually in medical negligence claims, with more than €2 billion paid out over a five-year period.

Sinn Féin would mandate the HSE to prioritise directly hired staff and in-house expertise, insofar as possible. We would require whole-time staffing equivalent data reporting for agency spending and consider this within the health service’s approved workforce to incentivise conversion of agency posts. This is essential for achieving value for money and building up expertise and experience in delivering on strategic priorities within the health service. We would require stronger appraisal and justification of external consultancy, and maximise insourcing within the Department of Health, the HSE, and the wider public service to conduct this work.

Significant efficiencies can be achieved by improving utilisation of existing resources such as theatres, outpatient clinics, and diagnostic and treatment equipment and machinery. This requires an alignment of staffing, work hours, and training places to facilitate improved productivity. Use of new technology and digitally assisted work practices can also be applied to drive day-to-day productivity increases.

Sinn Féin’s health plan, including investments in digital transformation, primary care, and targeted measures to support preventive and ongoing care in the community, would foster a most cost-effective health service. Significant savings can be extracted by clamping down on outsourcing, agency staffing, suboptimal medicine management, and by improving procurement compliance. We believe that savings on medicines should be re-invested in new products and innovative treatments.

Sinn Féin Will:

icon_check iconTarget €1 billion in savings and efficiencies across the health service, including major reductions in agency spending, reliance on overtime, and management consultants

icon_check iconImplement tighter control on use of outsourcing and management consultancy with more robust appraisal requiring justification for external procurement and accountability for in-sourcing and productivity

icon_check iconEnable greater accountability using an integrated financial management system, population-based budgets, and activity-based funding.

Sinn Féin would deliver an unprecedented investment in digital transformation to bring the health service into the 21st century. We would fund a radical modernisation of the health service to provide rapid access to records, improve health and spending data, and deliver digitally integrated care. This would significantly improve patient experience and cost efficiency.

We would provide for a ringfenced €2 billion health digital transformation fund. This fund would cover fundamental reform programmes such as integrated referral and waiting list systems, shared care records and developing a full digital health record, a patient app, and remote clinical services. It would also cover an integrated financial management system to improve spending accountability. This fund would provide space for innovation, research, and development within health regions.

Our digital health strategy would empower patients and clinicians with greater access to health information. We would fund the development of new infrastructure, ensure robust identity management, and enhance the collection, use, and sharing of health information for care and treatment. We would develop a digital portal to allow people to see exactly where they stand on waiting lists and manage their affairs.

We would prioritise the development of secure data sharing across primary care and hospital providers. The digital health service would be built gradually but consistently as trust is proven in complex health information systems. Fundamental performance and financial management systems must first be fully implemented and functioning. We would ensure that GP integration is covered from within this fund.

Sinn Féin Will:

icon_check iconEstablish a digital transformation fund which is ringfenced from the health capital budget worth €2 billion

icon_check iconImplement a multi-annual funding framework for digital transformation to deliver digital care records, a patient app, and improved waiting list and financial systems

icon_check iconInvest in digital technology to support care at home and for remote communities

icon_check iconEnact the Health Information Bill and health data space regulations

icon_check iconDevelop a one-stop-shop to concentrate expertise and drive innovation across the health system.

All Island Planning

Sinn Féin would work to maximise the potential of the all-island population to plan and develop specialist health services. Ireland has a population of just 7 million people, of whom 1.8 million live in the north. The island’s population is larger than Scotland, Norway, and Denmark, and compares to 10 million in Sweden and 18 million in Netherlands. We would work to increase all-island collaboration and maximise use of all-island healthcare capacity to tackle waiting lists and increase educational capacity to train healthcare workers.

Sinn Féin would maximise all-island cooperation to enable an appropriate flow of patient in both directions across the border according to local need and service provision.

The benefits of all-island planning in highly specialist areas have already been demonstrated in a number of important fields. Joint projects have been developed across radiotherapy, paediatric cardiac services, and cancer research. The all-island congenital heart disease network, based out of Dublin, Belfast, and regional clinics, has been highly successful and was implemented along with DUP Ministers of Health.

Partition disrupts health planning across Ulster. A 2011 report, commissioned by the Centre for Cross-Border Studies, entitled Unlocking the Potential of Cross-Border Hospital Planning on the Island of Ireland, identified several further areas for cooperation such as cross-border services at the South West Acute Hospital in Enniskillen, and potential for further collaboration across paediatric cardiac services, acute mental health services, orthopaedic services, otolaryngology (Ear, Nose and Throat), and Cystic Fibrosis services. This report focussed solely on hospital-based care and is now more than 10 years old.

Sinn Féin would commission a new report to examine progress since 2011 and identify areas for collaboration across a wider range of health and social care services, including the development of truly national centres of excellence based on the model provided by the all-island congenital health disease network. We would commission further research into cross-border and all-island collaboration across paediatric, cardiac, cancer, and genomic services.

Sinn Féin Will:

icon_check iconEnable all-island collaboration, research, and specialist service development

icon_check iconMaximise use of all-island and cross-border healthcare capacity

icon_check iconRevise national strategies to ensure all-island planning

icon_check iconIncrease cross-border education and workforce planning to train more healthcare workers, and align professional regulation and registration

icon_check iconEnsure cross-border engagement when considering the best local care options for border counties

icon_check iconCommission research to advance all-island and cross-border service provision,
Work with the Executive to establish an all-island public health emergency framework.

Health Regions and Integrated Management

HSE Health Regions would be drivers of reform under Sinn Féin. They must be more than a rearranging of the deck chairs. It must involve real integration of care as well as management responsibilities. Regionalisation reforms must cut through the layers of bureaucracy and deliver streamlined, accountable management. There must be a clear delineation of responsibility for defined areas across minimal layers of management. Health Regions would play a significant role in collaboration with educational institutions in implementing our workforce plan and expanding training capacity.

Regional management would be held accountable for improvements and performance would be monitored. We would judge performance on indicators such as improved coordination across acute and community services, delayed discharges, out-of-hour primary care activity, home care, and ED wait times. Progress would be expected at de-leveraging hospitals, improving efficiency, and managing spending.

We would mandate each health region to develop a population-based care and capacity plan to inform strategic investment and workforce planning. We would develop a population-based budgeting system, aiming to provide each region with current and capital funding proportional to the population they serve and balanced against legacy capacity deficits. We would develop an activity-based funding model for hospitals and other service providers to hold management properly accountable.

Our plan would enable a model of accountable autonomy for regional management to allow them to move quickly to address deficits across service divisions and create a framework for performance comparison between regions. Regional executives would be accountable for delivering efficiency improvements and value-for-money.

Sinn Féin Will:

icon_check iconStreamline management through Health Regions and hold executives to account for performance

icon_check iconMandate each health region to develop a population-based care and capacity plan to inform strategic investment and workforce planning

icon_check iconHold regions accountable for planning and delivering strategic infrastructure through investment frameworks

icon_check iconStrengthen governance, oversight, and accountability by flattening layers of management

icon_check iconEnsure diverse professional representation at regional management level

Infrastructure Delivery

We would give Health Regions multi-annual funding certainty to speed up the delivery of capital projects and address deficits in strategic infrastructure. We would ramp up the use of standardised designs, reduce decision gates, and require a multi-annual capital plan for each health region. Sinn Féin would ensure that past performance is taken into account in the awarding of public works contracts. We would review public works contracts to eliminate the weaknesses which are clear to see in the new Children’s Hospital project. We have discussed this further in our Report on Stakeholder Engagement: Understanding the Causes of Hospital Waiting Lists (2021).

We would make full use of existing planning mechanisms to fast track the delivery of beds, including emergency planning powers as has been done for other infrastructure projects in the past. The situation in hospitals is an emergency and needs to be treated as one, and planning priorities must be aligned across the HSE and local authorities.

Sinn Féin Will:

icon_check iconMake full use of existing emergency planning powers to accelerate infrastructure delivery

icon_check iconMandate multi-annual infrastructure planning to reduce planning delays

icon_check iconImplement multi-annual infrastructure funding frameworks to enable steady delivery

icon_check iconMaximise use of standardised designs and rapid-build technology to address capacity deficits

Patient Safety, Advocacy, and Complaints

Sinn Féin is committed to a culture of patient safety. We would put patient safety front and centre in accountability and reform.

Patient rights are at the centre of our approach to healthcare. Patients have rights to preventative measures, timely access to care and information, to give and withdraw consent, quality standards, privacy and dignity, respect, confidentiality, and, when things go wrong, the right to complain and, where appropriate, compensation.

There are many instances where patients and healthcare workers have felt unheard, dismissed, let down, or pushed away when making complaints about quality of care or conditions at work. Bias, whether real or perceived, is a major issue for the HSE. While the quality of care is generally quite high, trust in the HSE is quite low due to a lack of accountability and transparency.

Sinn Féin would prioritise independent complaints processes to improve trust in the handling of complaints. We would work with the HSE and across oversight authorities to deliver trust in the outcome of investigations. We would hold the HSE to account for cultural change to improve the working environment. Complaints should be user friendly and seen through the lens of a learning opportunity.

Patient advocates play a vital role in ensuring transparency, inclusivity, and patient-centred decision-making. We would ensure the availability of professional patient advocacy. We would ensure that patient voices are central to delivering healthcare reform.

We would review the implementation of new Patient Safety and related legislation, such as rules governing organ retention and disposal policies, to ensure they are working as intended and that there is consistent implementation.

Sinn Féin Will:

icon_check iconSupport professional patient advocacy and complete the Patient Voice Partner Voice Policy

icon_check iconPublish a framework for engagement with and supporting patient advocates which includes decision-making, a complaints procedure, and a formalised role for patient advocates

icon_check iconDevelop an independent body responsible for health service complaints and patient safety

icon_check iconReview the role and effectiveness of the National Patient Safety Office

icon_check iconReview the operation of the Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023

icon_check iconReview the operation of the Human Tissue (Transplantation, Post-Mortem, Anatomical Examination and Public Display) Act 2024

Safeguarding

Sinn Féin would enact adult safeguarding legislation. This would provide a legal framework to support safeguarding, additional powers for social workers and relevant social care professionals, and an agency, separate from the HSE, which is empowered to oversee safeguarding policy and practice across the public and private sector and in the home. We would increase resources and powers for safeguarding teams. We would legislate to provide a legal right of entry to any designated care centre for relevant social workers and social care professionals. We would legislate for a Care Partner scheme similar to that which operates in the north of Ireland. This scheme was highly successful at reducing isolation and improving health outcomes.

Sinn Féin Will:

icon_check iconEnact adult safeguarding legislation

icon_check iconIntroduce mandatory reporting of suspected abuse or neglect

icon_check iconProvide a legal right of entry for relevant social workers

icon_check iconEnact care partner legislation

Covid Review

Sinn Féin supports a transparent review into the handling of Covid-19 in public and private residential care homes. Access to records, closure for affected families, and the unnecessary isolation and substandard care experienced in some care homes must be definitively addressed.

In future public health emergencies, access to family support and social care practitioners must always be supported. We would legislate for a Care Partner scheme similar to that which operates in the north of Ireland. This scheme was highly successful at reducing isolation and improving health outcomes.

Sinn Féin Will:

icon_check iconAdvance a transparent review into the handling of Covid-19, with a specific module on residential care homes that provides closure and accountability.

Public Investigations

icon_check iconOversee the completion of the Farrelly Commission of Investigation

icon_check iconEstablish a Commission of Investigation into abuse perpetrated by former surgeon Michael Shine and publish the 2009 review

icon_check iconDeliver a State apology to Thalidomide Survivors and ensure access to the necessary lifelong health and social care supports

icon_check iconProgress the sodium valproate inquiry and ensure access to supports for FVS-affected survivors

icon_check iconPublish the Report of the National Vaginal Mesh Implant Oversight Group and ensure the availability of full mesh injury care, removal, aftercare and ongoing health and social care supports.