SECOND OPINION:HSE needs a radical overhaul of the way it does its work, writes JACKY JONES
I DESPAIRED when I read Government plans to restructure the HSE. We are now to have a directorate and seven “service lines”, each of which will have its own director. These are public health, hospital care, primary care, mental health, children and family services, social care, and corporate services. While this is a reduction in the number of directorates from the current 10 to seven, it will not solve the problems in the HSE, which are poor planning systems, little or no integration, and no synergy.
One of the new directorates will be called “public” health. This is an example of how the language changes but the problems remain. What happened to “population” health?
When the HSE was established, population health was the new mantra which was supposed to revolutionise the way health services were planned and delivered. The concept was developed in Canada and New Zealand and involves – in this specific order – community profiling, considering the evidence, involving the public, talking to service providers, and finally planning, implementing and evaluating health services.
While the population health approach is good in theory and the practice has worked well in other countries, its implementation by the HSE has been a dismal failure. For a start, the first four elements are hardly ever included in the service planning process. This habit of knowing the answers before the questions have even been asked is a fault of all professionals everywhere and especially in the Irish health services. A Population Health Strategy published by the HSE in 2008 was supposed to integrate the services of the different directorates but this didn’t happen. If anything, things got worse.
Bemused readers are probably wondering about the difference between “public” and “population” health approaches to planning. Surely they mean the same thing? Well, yes, if you are a service user and, no, if you are a service provider. The difference between the two is that having the word “public” in a directorate’s name means it is led by a doctor of public health medicine, whereas, the word “population” is not owned by any professional group and involves a synergistic partnership between health professionals where all partners are equal. The population health approach leads to better outcomes. The concept failed miserably in Ireland because of a lack of leadership and the turf wars that resulted when the HSE tried to implement it. The synergy needed never materialised.
Turf wars are not confined to a population health approach to service planning. They happen throughout the HSE in all except emergency situations where health professionals can focus solely on better outcomes.
Competition between disciplines means that, whether there are seven directorates or 20, there will be no synergy without integrated planning systems and collaborative leadership to make it happen.
Synergy comes from the Greek word “synergos”, which means to work together so that the whole is greater than the sum of the parts. In terms of health services, synergy is the degree to which HSE managers are able to combine the complementary talents and skills of staff in the search for better solutions to health problems.
Turf wars between health professionals lead to inertia where the whole is less than the sum of the parts. The amount of time wasted because of professional rivalry within the HSE is incalculable.
A synergistic working environment is energetic and passionate, extra outcomes are achieved, work is broken down and shared, and everyone is more satisfied, especially service users.
An environment without synergy is a miserable place to work and leads to high sick-leave rates, which are a massive problem in the HSE.
Synergy can be developed by integrated service planning systems which force people to work together and regard all health professions as of equal value. This does not happen in the HSE. It is doubtful if current directors understand what integrated planning means, let alone have the skills to do it. Directorates still do their own service plans, which are cobbled together into an incoherent whole.
The miracle is that, in spite of poor planning systems and lack of collaborative leadership, health services at the front line are generally excellent. There are just not enough of them because so much time is wasted on bickering between professions. We can only hope that the new structures will not just be name changes and fewer directorates, but will include synergistic planning systems. Otherwise nothing will change.
Dr Jacky Jones is a former regional manager of health promotion with the HSE