Phoenix: Bureaucratic endeavour

At this stage, a short few weeks into the US presidency of Donald Trump, most people are familiar with Elon Musk and his Department of Government Efficiency or DOGE as it is called. 

Musk’s brief from Trump is to eliminate “waste, fraud and abuse” across the US administration. His actions have leaped into the public eye through his threats to sack hundreds of thousands of US federal workers. 

“Send me an email with five bullet points saying what you did last week. Failure to reply means you’re sacked or that you have resigned.” 

Musk believes that bureaucracy is hugely expensive, overly regulating and works for its own ends and aims. 

It is interesting to consider the origin of the word bureaucracy itself, which comes from French, meaning desk or office. Originally it was a type of cloth used for covering desks and tables. 

The context for Musk’s US actions is that the public and civil services are bloated and lazy and need a good old private sector slash and burn. Lean systems are his gospel.

The view of bureaucratic waste is widespread in Ireland when people refer to the HSE in particular or the public service in general. 

Failure to achieve housing targets are blamed on bureaucratic slowness, inefficiencies and over-regulated planning systems. 

Waiting lists and inefficiencies in our public health system, which is operated by the Health Service Executive, are constantly blamed on the recruitment of bureaucrats and managers, instead of front-line staff, such as doctors and nurses. 

Descriptions of administrators and managers range from the impolite to the awful and everything in between. People are called folder holders and jobsworths and worse. 

Yet modern systems cannot work, despite the eternal fascination with technology and digital applications, without an efficient team of real people. That is particularly true in our health service, although anyone who has been in any of Ireland’s public hospitals will be familiar with the truck loads of patients’ files being wheeled around from ward to ward and from department to department or indeed with the seemingly never ending process of being asked again and again for the same information.

Free healthcare at the point of use was the core principle of the UK’s National Health Service, which was established by the British Labour government in 1948. 

Labour's Minister for Health, Aneurin Bevan, is considered the NHS's founder. The wheel is coming full circle and NHS England, dubbed the “world’s largest quango”, will be abolished to “cut bureaucracy” and bring management of the health service “back into democratic control”, according to Keir Starmer. 

The UK Prime Minister said decisions about billions of pounds of taxpayer money should not be taken by an “arm's length” body, as he promised sweeping reforms, which the Government says will deliver better care for patients. It all sounds so familiar and so predictable.

Ireland has never had a free at the point of use health system, except for holders of medical cards. Our particular predilection is health insurance. Apparently half the population (47%) is covered by such insurance mainly in the belief that they will have quicker access to hospitals and to medical treatment if they become ill. The corollary is private hospitals, so Ireland has a binary system mixture of public and private healthcare. 

The public healthcare is delivered by the HSE, which was established by the Health Act 2004 and came into official operation on 1 January 2005. It replaced the regional Health Boards, the Eastern Regional Health Authority and a number of other different agencies and organisations. 

The health boards system of Ireland was created by the 1970 Health Act. This was initially created with eight health boards, each of which were prescribed a functional area in which they operated. It was reformed in 1999 from eight to 11 regional bodies. 

The system went from eight CEOs, and eight management systems to 11 individual systems, in a massive expansion of bureaucracy and administrative personnel. 

The extra systems were put in place in the Dublin area by creating four health boards from the old Eastern Health Board. 

These boards had political representatives so this increased the Dublin area demand for capital investment. Dublin County Council was split into three county councils, which, with Dublin City Council, means there are now four local authorities in county Dublin, each with their own CEOs, staff and political representation, each with their own development plans and each seeking investment from central funds. 

Bureaucracy seems almost like mitosis, where a cell duplicates all its contents and splits to form two identical daughter cells. 

The developmental impact on Dublin was enormous and to the detriment of investment in areas like Waterford (think DCU versus WIT). 

The HSE was meant to deliver efficiency, but there were no job losses, everything pre-existing was simply rolled into one unwieldy new organisation. This meant the new entity was administratively heavy from the start, but had no local political representation. 

This allowed the government to treat health services at arm's length. Write a letter of complaint to the Minister for Health and you get an answer saying, “your letter has been referred to the HSE for reply”.

Massive growth in tax receipts over the past few years has allowed a huge increase in HSE budgets and manpower. 

HSE spending has increased annually. Between the years 2018 to 2022, there was a total increase of €7.26 billion (45%) in budget. The HSE 2025 budget is €26.9 billion, which is a €1.6 billion increase on the 2024 figure, yet waiting lists and trolley numbers continue to grow. 

Locally, UHW has seen an uptick in budget and staff in line with the national increases yet the hospital is light on staff numbers. 

Meanwhile, headlines shout, “Waiting lists surge at UHW”! 

If Mr. Trump gets serious about US investment in Ireland and there is a decline in government revenue, how long would it be before an Irish Taoiseach says ”the HSE is Ireland’s largest quango and must be abolished to cut bureaucracy to bring health spending back into the Department of Health under direct government control”? 

Would that centralisation benefit Waterford or would it increase the impact and power of those with political clout? I rather fear the latter.