Better way to manage HSE needs to be found

ANALYSISGROWING ANECDOTAL evidence that the Health Service Executive is a dysfunctional organisation delivering a service insensitive to the needs of patients was confirmed with the recent publication of three reports into the Portlaoise breast cancer debacle.

The report by John Fitzgerald, the former Dublin city manager, was especially revealing. His conclusions were stark and damning, finding evidence of systemic weakness in governance, management and communication within the HSE.

While a decision has been made to soldier on with its present structure and focus instead on improving work practices within the HSE, there is a need to take a fresh look at management issues within the national health authority.

The board of the HSE, in the wake of Fitzgerald, must ask itself is there more it can do to turn the ship around. One of the key appointments to the HSE board was Niamh Brennan, professor of management at University College Dublin and author of the Brennan Report, which heavily influenced the management goals of the fledgling HSE.

One of her report's main recommendations was the need to have tight "head office" control of services and resources. This has clearly been achieved, but at a cost to patients.

By overcentralising decision making, the HSE has emasculated local and regional managers. This, in turn, threatens existing front-line services. So not alone is the development of new services extremely slow, but the resignation of an existing nurse, therapist or psychologist risks collapsing a well-functioning healthcare team. Why? Because in order to recruit a replacement the decision has to be referred up the line for central approval. As one senior official dryly observed last week, "decision-making ability is indirectly proportional to the number of managers involved". Even if central approval eventually emerges, the extended delay means existing patients lose out.

As emphasised by Prospectus management consultants in another key health system report, the essence of really good clinical governance is to place the patient at the centre of the decision-making process.

Sadly, this is not happening in practice. The accountancy function, while important, has unnecessarily buried the needs of the patient. The Portlaoise debacle, with test results announced to the Oireachtas Health Committee before individual patients were informed, shows just how endemic this culture has become.

But there is a better way, and it has been demonstrated successfully in Britain. Prof Aidan Halligan, one-time favourite for the job as HSE chief executive, led a successful initiative to imbue clinical governance as a core value in the National Health Service.

A key element was to set up a number of small teams that visited front-line services throughout England and Wales. And while they may have started by targeting known problem areas, they soon received invitations from apparently well-functioning units keen to do better.

The Health Information and Quality Authority (HIQA) will ultimately perform a similar function in the health service here. In the meantime, is it asking too much of Prof Brennan to chair a sub-committee of the HSE in order to identify even a half-a-dozen services that would benefit from a clinical governance blitz?

They could then lead a small team of committed staff that would work with the chosen services to measurably improve the lot of patients.

Critics might see such an initiative as a mere drop in the ocean but the experience elsewhere is that this approach produces a ripple effect that extends beyond its immediate focus.

And in a foundering health system with rock bottom staff morale, the initiative could help steady the drifting HSE ship.

It cannot be easy being a manager in the HSE at present. Because of the "common recruitment pool" system in the health boards, certain vacancies at senior administrative grades could only be filled from within the pool. The common recruitment pool was a "defensive" agreement reached in 1970, aimed at preserving promotional opportunities within the system.

Along with the traditional recruitment of health service administrative staff straight from secondary school, are we now seeing the effects of this policy in poor management performance?

Is it time to consider setting up an educational facility similar to the École Nationale d'Administration (ENA), where many of France's senior civil servants are instructed?

Notwithstanding the management courses already available here, a dedicated school for health managers would help to instil an "esprit de corps" among its graduates. And by bringing together international researchers and leaders in the field of public health management, its influence on current health managers would be positive.

There are no easy answers to the many problems in the public health service. But no matter how intractable they seem, we must keep looking for solutions.

Dr Muiris Houston is medical correspondent of The Irish Times.