It was April when Tony Canavan sounded alarm bells within the State’s health service about the risk a decision to scrap an initiative to reduce waiting list numbers nationally would have on patients in his region.The man responsible for the health service in the HSE’s West and North West region claimed the cessation of insourcing – a measure aimed at slashing waiting lists by allowing private companies use HSE facilities and staff – created a “significant risk of unintended harm to patients”. He warned in a report of increased waiting lists, loss of momentum and delays to care. The region presented a number of options to mitigate these risks, including a region-specific allowance, but the national office said there would be no special derogations.This decision resulted in significant frustration at senior management level across the HSE’s regions, according to sources familiar with the proposals.The difference of opinion is about more than just waiting lists; it is also emblematic of the challenging nature of management relationships since the health service was reformed into six regional structures in 2024.The aim of overhauling the health service into six regional areas was to integrate hospital and community services to improve the HSE’s ability to care for the specific needs of the local population.The regional structure is considered key to delivering Sláintecare, the 10-year plan to move to a universal health system where medical care is based on an individual’s need rather than the ability to pay for it.Previously, the health system operated through nine community healthcare organisations and seven independent hospital groups, with high-level decisions issued from a central, national headquarters in Dublin.[ HSE decision ‘could add 4,000 patients per month’ to waiting listsOpens in new window ]Now each of the six regions has its own executive officer and management team. The regional executive officers have a starting salary of about €235,000. The next tier, known as integrated health area managers, are paid about €193,000.Speaking at a conference last September, Taoiseach Micheál Martin described the regional structure as “critical” for Sláintecare. The changes, he said, had strengthened and streamlined governance and improved delivery. Six months later, the board of the HSE appeared to be less impressed with the impact of the changes on the ground. Members expressed concern that the operation of the six regions appeared patchy, according to the official minutes from its April 29th meeting.The board meeting was held after a deterioration in the HSE’s financial position in the early part of the year and the decision by its national chief executive Anne O’Connor to place three regions under escalated measures, where greater financial controls were applied.To rein in spending, regions, which are responsible for their own funding, were told to move away from a reliance on outside agencies and convert these workers to permanent posts.At a recent meeting of the Oireachtas health committee, Minister for Health Jennifer Carroll MacNeill said this desire was “more difficult in some regions” than others.“For example, the hospitals in Dublin-mid-Leinster have a much higher proportional reliance on agency than hospitals in other areas. That is a huge cost,” she said.However, she noted the West and North West region was “doing quite well” in this regard.The Government has also been assessing the performance of the HSE regions on another issue: the implementation of the public-only consultant contract (POCC).A June 30th presentation document by the Department of Health, seen by The Irish Times, shows the regional variation on the uptake of the contract. The Mid West had the lowest uptake, with 51 per cent of consultants on the contract, while Dublin and North East had the highest, at 74 per cent.The new contract seeks to increase the number of senior medical decision-makers onsite in the evenings and weekends. But the document shows the implementation of this is also varied.The Mid West had the highest proportion of consultants working extended working days during the week, at 70 per cent, while this figure was only 28 per cent for HSE South West. On Saturdays, only 7 per cent of consultants in the HSE Dublin and North East region were rostered to work, compared to the much higher figure of 48 per cent in the Mid West.Speaking recently, Tánaiste and Minister for Finance Simon Harris said there was a need for improvement and greater consistency in implementing the contract across the regions.It was a point that could have been taken from the minutes of the meeting of the HSE board on April 29th, published earlier in July.“Board members noted the need for greater clarity and consistency in governance structures, alongside stronger central oversight and co-ordination,” the minutes state.[ Removing private practice in public hospitals under new contracts ‘inadequately monitored’Opens in new window ]“It was recognised that the current model has reduced visibility and oversight at the centre, with some regional functions operating with significant autonomy, making it more challenging to maintain a consistent view of performance across the system.”Members of the HSE board described the performance of the regions as “variable” and discussed whether additional senior-level support might be required to strengthen oversight, co-ordination and decision-making in the organisation.The board believed existing reporting arrangements “were considered insufficient in providing a clear picture of operational performance and emerging risks, highlighting the need for more robust and actionable information”.Board members maintained that while the new regions were “broadly operating as intended”, they had concerns “about capacity in some areas to manage ongoing financial and operational pressures effectively”.The board noted “particular challenges” on pay and non-pay management, disabilities, mental health and income generation, but said these pressures were being experienced across the health system.“The board considered the significant financial challenges facing the organisation and emphasised the importance of maintaining strong financial discipline while continuing to deliver services in a high-demand environment. Different views were expressed on the balance between regional autonomy and increased central oversight, with agreement that any changes to authority arrangements would require careful consideration,” the official minutes state.This issue was raised in last year’s budget when, for the first time, funding was devolved to the regions.Newly appointed secretary general at the Department of Health, Derek Tierney, said he heard concerns about the reforming of the service into regions, particularly in the delivery of cancer care.The success of the regional model will ... depend on whether decision-making is genuinely devolved. The introduction of HSE chief executive approval for purchases above €10,000 appears difficult to reconcile with that ambition— Mo FlynnThe “whole purpose”, he told the Oireachtas health committee, was to give “regional autonomy supported by a strong centre”.“The challenge is to understand how we achieve this balance between national health service delivery through clinical programmes and, ultimately, service delivery.”While the Taoiseach maintained that the health reforms served “to both strengthen and streamline the governance of our health system”, others argue that more work needs to be done.A number of the regions, particularly those serving parts of Dublin and Cork, also cover voluntary hospitals with their own governing boards, as well as HSE facilities.This has led to questions about potentially conflicting reporting relationships where hospital managers answer both to their own boards and the regional HSE leadership.Members of the HSE board described the performance of the regions as 'variable'. Photograph: iStock Sara Burke, associate professor and director of the Centre for Health Policy at Trinity College Dublin, said she was not surprised at the concerns raised by the HSE board about inconsistency in the performance of the regions.She maintained there had always been a lack of clarity about who was responsible for what in the health service. She said this question had been raised as far back as the Commission on Health Funding in 1989 and was still relevant.“It takes leadership, investment and governance from the centre – the HSE nationally and the Department of Health – in order for the regions to perform well and consistently,” she said.A survey by the Irish Voluntary Healthcare Association (IVHA) also indicates that among chief executives and the chairs of the boards of voluntary hospitals and hospices, there are concerns about the operation of the regions to some degree.The IVHA found relationships with local HSE contacts were often constructive. It said 56 per cent described their relationship with the HSE as mostly positive. [ HSE under pressure over health agency staff as Opposition claims spending is risingOpens in new window ]“However, respondents also identified persistent challenges, including insufficient budgets, failure to fund capital developments, poor engagement, increased administrative burden and concerns around governance,” the association said.Mo Flynn, chief executive of the IVHA, said the establishment of the HSE regions had required “considerable focus on creating new structures and appointing leadership teams”.“While necessary, this has delayed progress towards delivering integrated care and advancing the ambitions of Sláintecare,” she said.“The success of the regional model will also depend on whether decision-making is genuinely devolved. The introduction of HSE chief executive approval for purchases above €10,000 appears difficult to reconcile with that ambition.”Despite the concerns raised within the HSE, the Minister for Health in May denied that splitting the health service into regions had been a mistake, although she acknowledged the different experiences across the regions.“This is the first year where we are devolving funding structure; it’s always going to be a certain amount challenging,” she said.