The deep-seated problems at the HSE identified in this week's three reports on failures at Portlaoise hospital are traced back to the organisation's troubled inception in the first of a two-part investigation
This week, controversy surrounded the publication of three reports inquiring into the misdiagnosis of nine women with cancer in Portlaoise. Each report is damning about the breast cancer services in Portlaoise. But there is also strong criticism of the HSE's failure to manage, govern and communicate effectively.
When Mary Harney and Prof Brendan Drumm appeared before the Oireachtas Health Committee on November 22nd last, politicians and the public, including patients, were informed for the first time that two separate reviews were taking place, one of mammograms, by a specialist from Breastcheck in St Vincent's and another of ultrasounds, to be conducted locally in Portlaoise.
Although the Portlaoise cancer crisis had been top of the political and public agenda since August, no one in the senior management of the HSE nor in the Department of Health had been aware of these two reviews until the night before the Oireachtas committee meeting, on November 21st.
And significantly, patients only became aware that their cases could be part of the review through media coverage of testimony to the committee by John O'Brien, the acting head of the National Hospitals Office.
Within a week, the board of the HSE (under instruction from the Department of Health), commissioned former Dublin city manager John Fitzgerald to review the HSE's management of all decisions surrounding the cancer controversy.
According to Fitzgerald's review, problems arose from "systemic problems of governance, management and communication". His report does not point the finger at any one individual, because "many people were working under significant pressure, with multiple important matters vying for attention". His primary conclusion is that "there was a fundamental weakness in the management and governance of this process from the outset, because there was no authoritative co-ordination and management role established . . . ".
In relation to weaknesses in management and governance, Fitzgerald assesses that the problem was compounded because "there were too many people involved from different levels and areas within the HSE, without clarity about their roles and responsibilities within the process . . . the decision-making process was fragmented, with insufficient clarity about decisions, who was making them, why they were being made, or when they were signed off".
He concludes that "the communication difficulties that arose cannot be separated from the weakness of management and governance", that ultimately patients' needs did not receive the urgency or attention required between August and November 22nd.
WHEN IT WAS set up three years ago, the HSE was heralded as the body that would bring integrated and accountable health and social services to Ireland, alongside better value for money.
The story of its foundation begins with a flurry of health reform at the beginning of this century. In 2000, health and social care services were more comprehensive than there had ever been before in the history of the State. But the 11 regional health boards, which ran or funded most health and social services, had been in operation for 30 years without much change. They lacked consistency, and standards and were overly influenced by local politicians. And they were under increasing pressure to provide more services.
According to Prof Orla Hardiman, consultant neurologist and spokeswoman for Doctors Alliance (a lobby group formed in 2007 that advocates better public healthcare), "each health board area was an independent fiefdom - politicians liked them as they could get medical cards for constituents". Expected to provide more services for a growing population, with increasing costs, alongside rising demands from the public, the health boards and hospitals consistently ran over budget.
Between December 2001 and June 2003, the then Minister for Health, Micheál Martin, presided over the publication of the National Health Strategy, the Primary Care Strategy, the Prospectus report (an audit of structures and functions), the Hanly report (on medical staffing), and the Brennan report (on financial management and control systems), and the administrative reform programme, which established the Health Service Executive.
The 2001 health strategy promised better health for all, equity and fairness, 3,000 additional hospital beds, and quality community and primary care services. But, in the years that followed, the health services continued as before - incrementally growing to meet demands but without any radical restructuring.
The Hanly report had been the most controversial of all, with significant recommendations on the establishment of regional networks of hospitals, which would require decisions on which hospitals would become regional hubs and which would not.
The location of hospitals is one of the most contentious issues in Irish politics. Part of the rationale for the establishment of the HSE was that the reorganisation of hospitals would never happen as long as local politicians were on the local health boards.
Both the Brennan and Prospectus reports recommended reform through the establishment of one central executive, although they differed on the strategy and objectives. According to the Prospectus report, the purpose of reform was to create "a consolidated healthcare structure, putting in place a single Health Service Executive to replace the existing health boards", delivering "value for money and managing ongoing change" and ensuring "simpler governance and greater accountability".
The Brennan report concluded that "the management vacuum at the heart of the health service must be addressed urgently. We believe that national management of the health service would best be delivered outside the structure of the Department of Health and Children and are recommending the establishment of an executive at national level for this purpose. This would allow the Department of Health and Children to focus more fully on health policy."
The new structure selected for the Health Service Executive was closer to the Prospectus than the Brennan model. Brennan had recommended a single authority to manage the health boards, although the number and configuration of the boards could have changed. Prospectus recommended one single executive, with four regional offices but no health boards (and therefore no politicians). Liam Doran, outspoken general secretary of the Irish Nurses Organisation for the past 10 years, says "Setting up a Health Service Executive seemed to make sense. In 2003 and 2004, most people said 'yes, it's worth a go'."
IN NOVEMBER 2003, Micheál Martin appointed an interim HSE board, with Kevin Kelly as chairman. Kelly was managing director of AIB Bank from 1996 to 2001, a former chairman of the Irish Management Institute and former president of the Irish Banking Federation. He encouraged the use of the language of the market in Irish healthcare: "patients" became "clients"; if the public health services were failing, then the private sector could provide some of the solutions.
Between the publication of the health strategy in December 2001 and the coming into being of the HSE on January 1st, 2005, much of the time and energy of senior management in the Department of Health and the health boards went into reforming the structure and administration of the country's health services. Amid this rush for reform, there was no move to address the fundamental structural inequality in the health services - the fact that people who can afford private care access medical services quicker than those who cannot.
The Department of Health led a slow process through the second half of 2003 and the first half of 2004, combining the Prospectus, Hanly and Brennan reports into one coherent strategy. From November 2003, Kevin Kelly was centrally involved in this process. Some senior health sector personnel from the health sector who worked with Kelly during this time express frustration at his drive to "commodify health and social care", alleging he "lacked empathy for the ethos of public services".
According to Donal Duffy of the Irish Hospital Consultants Association, "it was like they [ the department and interim HSE board] threw the three reports in the air, and what came back down was the HSE". Yet there was agreement from everyone involved that there was a need for a unified executive responsible for delivering all health and social services.
The new HSE structure was due to be in place on January 1st, 2005. Following the June 2004 local elections, politicians were not reappointed to the local health boards.
The interim HSE board had tried unsuccessfully to recruit a chief executive. While some of the old health board chief executives applied, Aidan Halligan, the Irish-born and educated deputy chief medical officer in the NHS in England, was appointed to the position. Just before he was due to start, in November 2004, he decided not to take the job. In the absence of any other candidate, Kevin Kelly was appointed interim chief executive and Liam Downey was appointed chairman of the HSE board. Just before Christmas 2004, the Health Act 2004 was rushed through the Dáil in three weeks, following an acrimonious debate, without sufficient time for discussion or amendment.
Senior officials from the unions and the Department of Health say they were encouraging a voluntary redundancy package to be put in place, but government was adamant such a package wouldn't be offered. The establishment of the HSE was happening at the same time as the decentralisation of government departments and State agencies and the government was opposed to any voluntary redundancies as part of decentralisation.
Days before the HSE was due to be established, staff and management were still unclear as to new structures and reporting mechanisms. On December 23rd, 2004, Kelly did a last-minute deal with public-sector union Impact - which was threatening industrial action - guaranteeing all administrators and management staff jobs of equal standing in the new organisation.
Maureen Browne, who was acting director of communications in the new HSE from January to June 2005, wrote retrospectively in her Irish Medical News column that "it would have seemed prudent to many to defer establishment day to provide time for further measured discussion. However, this was not to be and, with hopelessly inadequate preparation and even less infrastructure agreed, the HSE went live at the beginning of January."
Tens of thousands of people went into work in the new year of 2005 not knowing to whom they should report, whether their role was to change, what their responsibilities would be, or where they would be based.
The HSE structure, conceived in Micheál Martin's time, was to be delivered by Mary Harney, who had taken over as Minister for Health in September 2004. Announcing the Health Bill in the Dáil in November that year, she said that "the key to the Health Bill is clarity, clarity of roles and clarity of responsibility - the Minister for Health will retain clear accountability for our health services . . . Most of all, people will have clarity about who is in charge of policy and who is in charge of the management of the health services."
THE THEORY OF the new structure was simple. The Minister for Health and her Department are responsible for health policy and legislation. The Minister appoints the board of the HSE. The board appoints the chief executive of the HSE (except for the first one, who was appointed by the Minister). The HSE manages and funds all health and social services.
Writing in early 2006, Maev-Ann Wren and A Dale Tussing, in their book How Ireland Cares, noted that "the legislation providing for the establishment of the HSE, the Health Act 2004, passed all stages in the Dáil in a guillotined debate in November and December 2004, without time for many provisions to be discussed and fully understood within or outside of the Dáil, even by the then government which promulgated them. There was no White Paper outlining intent of the legislation. The policy-operations divide between Minister and CEO leaves great scope for confusion and blame."
Meanwhile, services on the ground continued as before. While there were new national and regional management structures, day-to-day health and social care services were provided by the same front-line staff, out of the same locations.
During 2005, many senior managers moved on to positions in other, more sought after, public sector jobs, while others moved into the private sector. The HSE lost a whole cadre of its most experienced staff but was unable to recruit senior management positions from the outside. Workers on the front line were unsure of their line management and the burgeoning bureaucracy, while the public struggled to understand the new structures.
"It went wrong from day one. The transition period was handled abominably. Even the CEOs were sidelined. There were unnecessary levels of delay and inertia," says Liam Doran.
In June 2005, Prof Drumm, a consultant paediatric gastroenterologist based in Our Lady's Children's Hospital Crumlin and a UCD professor, was named as the new CEO.
Yet, within weeks, Prof Drumm held a public press conference in Crumlin hospital to announce he would not be taking the job. According to Mary Harney at the time, "Drumm had been offered the job, but a failure to reach agreement on one aspect of his contract led to negotiations with him irretrievably breaking down".
However, two weeks later, after much political persuasion and a rescue package being put in place, Prof Drumm was back in line for the post and came into office two months later, in August 2005. As part of the deal done, alongside his €400,000 pay package, Prof Drumm got agreement to bring with him a special "cabinet" of six to spearhead reforms, and €1 million a year to spend on these advisers.
Prof Drumm took over a structure that loosely followed the recommendations of the Prospectus report. However, many of the required associated actions recommended in that report were diluted or have taken a long time to happen. For example, Prospectus recommended the devolution of resources and decision-making to as local a level as possible. The structure in place is more centralised and monolithic than envisaged in Prospectus. Also, Prospectus recommended the immediate establishment of an independent Health Information and Quality Authority (HIQA), which was only established last May. The HIQA is an essential part of ensuring quality services and patient safety. As a result, three years after the HSE was set up, nursing homes are still not inspected by the HIQA and private hospitals do not come under its remit.
The HSE did adopt the Prospectus model of three pillars: the National Hospitals Office (NHO); Primary, Community and Continuing Care (PCCC); and Shared Services. Ten networks of hospitals, four Regional Health Offices and 32 Local Health Offices, Expert Advisory Groups and care group directorates were also established.
Pat McLoughlin, the first National Director of the National Hospitals Office, who resigned in January 2006 when the HSE failed to agree on his contract, says "no one underestimated the extent of change required to go from 11 boards into one streamlined system". Three years on, one of the three pillars - Shared Services - has disappeared, while the Hospitals Office and PCCC are located in Health and Personal Social Services alongside Population Health. There are also three other sections: Support Services; Reform and Innovation; and the Office of the CEO.
Ann Doherty, who was head of the HSE's corporate planning and control processes, has just been appointed new interim head of the National Hospitals Office, while John O'Brien, who was acting NHO head, is returning to his role as a strategic adviser to Prof Drumm. A letter from Prof Drumm to HSE management in the first week of January this year, announcing Doherty's appointment, also informed them of the setting-up of a high level team to oversee integration of NHO and the PCCC services. Rumours abound that it is a matter of time before four regional structures are in place, integrating hospitals and primary, community and continuing care services.
One senior administrator closely involved in the establishment of the HSE, who does not wish to be named, says, "the setting up of the HSE was meant to enable management to make the right decisions in the right place. Instead it's been a dysfunctional process, it was never meant to centralise services and there's a serious lack of concrete leadership. Portlaoise demonstrates that at every level of management. The rhetoric is there, but there is no follow through."
Sara Burke is a freelance journalist and health policy analyst