Prof Brendan Drumm tells Health Correspondent Eithne Donnellanabout the challenges he faces in running the HSE.
He arrives flanked by a couple of press advisers and with a bundle of paper under his arm, on which notes have been hastily scribbled in blue ink. It's the end of yet another day at the helm of the Health Service Executive for a rather pale-looking Prof Brendan Drumm. He has a job many would regard as a poisoned chalice - with responsibility for a multi-billion-euro budget, over 100,000 staff, and the task of implementing a major reform programme destined to meet with stiff resistance. Yet, halfway through his five-year term, he confides that one of the biggest challenges for him has been his loss of anonymity.
"That turned out to be in many ways one of the biggest challenges - the fact that everybody suddenly recognises you," he says.
That said, he insists most people who come up to him on the street don't have a complaint, but encourage him to persevere.
That may be so, but in the houses of the Oireachtas and in the media, as well as at public meetings and other forums, the HSE comes in for a constant barrage of criticism for its bureaucracy, its recruitment ban, cost-cutting measures, and the slow pace of decision-making within the organisation.
Most recently, it came in for stinging criticism over the manner in which it announced plans to recall for surgical review close to 100 women who had undergone breast ultrasounds at the Midland Regional Hospital in Portlaoise. The news was delivered out of the blue at an Oireachtas health-committee meeting. The women being recalled hadn't been informed. In fact few - not even Minister for Health Mary Harney - seemed to have been aware the review of ultrasounds was going on. The public focus had been on a review of mammograms carried out at Portlaoise that found nine women had wrongly been given the all-clear for breast cancer.
But Drumm defends the HSE's handling of the episode, stressing the organisation was in a no-win situation. He says it was decided going into the Oireachtas committee meeting that, if asked questions about the ultrasound review, which he had become aware of the pervious night, they would be answered.
But the HSE delegation at the committee, which apart from Drumm included the head of the HSE's National Hospitals Office, John O'Brien, wasn't asked about the ultrasound review, only about the review of mammograms carried out by Dr Ann O'Doherty of BreastCheck. When dealing with that issue, O'Brien slipped out new information about the ultrasounds review and the fact that 97 women were about to be recalled.
Drumm says of it all now: "A lot of the criticism that we suffered in relation to cancer related to the ultrasound issue and I think a lot of it revolved around the disclosure by us at the Oireachtas committee that an ultrasound review was ongoing. In reality, if you look at it the other way, if having been asked a question at an Oireachtas committee we did not declare the information we declared, and over the following week people were being phoned to come for review following a review of their ultrasounds, there would have been uproar about our failure to disclose. So, you know, some of these situations are no-win situations.
But he accepts that the issue of when to inform patients in reviews is something on which the HSE needs to focus and improve.
Drumm acknowledges confidence in cancer services was dented by the recent cases in which women were misdiagnosed. But he stresses that people have to realise there is always going to be an error rate. "What we have got to do is to minimise that error rate with the systems that we put in place."
Does this mean there will be more misdiagnosed patients coming out of the woodwork? "Will I ever have a system in a HSE that I could put my hand over my heart and say that there would be no missed cancers or misdiagnosis? the answer is I'm afraid I won't. As I said, what we have to have is a system that minimises that."
He says one wouldn't be human if one weren't heartbroken for the patients who were misdiagnosed, but that the important thing is to review what happened and to learn from the mistakes. "As an organisation we should welcome comprehensive reviews of what happens in our system. We shouldn't fear shining the light totally within our system. If we've made errors we should stand up and put our hands up and say we've made an error, we're sorry, and we want to learn from this and make sure it doesn't happen again."
IN THE MIDST of a range of controversies about cancer misdiagnosis, it emerged that a pathologist, put on sick leave by his employers in Finland, had come to work for a number of months at two HSE hospitals in Galway and Cork. Asked how this could happen, Drumm refuses to be drawn, saying he will have to await the findings of a review being carried out by the Health Information and Quality Authority into practices at the laboratory of Galway's University College Hospital while the pathologist worked there.
"I couldn't comment on an individual, to be fair, without a process being gone through," he says. "I think the major question for us has to be: was there a risk to patients in terms of somebody's capacity to carry out their job day to day? That's a huge question for us and that's what we need to get to the bottom of."
If it were the case that somebody was working here while on sick leave from a job in another country, that would be "a fraud on the other country", he states.
Drumm is anxious to learn from mistakes and to move on. Tight budgetary controls have been put in place for next year so as to avoid further overruns. When the HSE faced a multi-million-euro overspend at the beginning of September it imposed a recruitment ban and other cost-cutting measures, which will continue until the end of this month. But then they will end. "I don't think there will be any recruitment ban into next year," he says.
HSE figures indicate 1,024 people were dropped from the payroll by the end of October as a result of the ban. Drumm emphasises that, despite the ban, key frontline posts were still filled over the past few months. In all, he estimates about 700 vacancies were filled. But the pay bill was still reduced by €18 million per month between August and October.
The cost-cutting measures put in place by the HSE saved about €100 million and about €70 million of it came from the HSE's "altered recruitment policy".
He argues that many of the organisation's budgetary problems were not of the HSE's making, as it had to fund demand-led schemes and treat more patients than it had been funded for.
ON THE TIGHTER financial controls put in place for the new year, he says: "As of January 1st, for the first time ever, everybody in this organisation who is a budget-holder will be identified . . . each and every one of them will know that there will be no more money later in the year. Each and every one of them will be absolutely clear that we will not be moving money from capital to bail out overspends."
He reveals that the review of administrative posts in the HSE is likely to be completed by the end of March. It began in the face of ongoing claims from politicians and others that there were too many pen-pushers or bureaucrats in the organisation. Drumm says there may be "a few people here or there" who could opt for the voluntary redundancy scheme Harney says she would be in favour of for the HSE, but he feels the organisation more or less needs the number of employees it now has for the way it does its work.
"I think the major challenge that faces the HSE is actually not how many people work - that's obviously a challenge - but it's how we work," he says. "There is no doubt that the number of people we have at the moment is required to provide the services in the way that we provide them, but I have constantly since I've come here spoken about the complexity of the system and the fact that we provide services totally separately in our hospitals and then in our community. We have to make that simpler and much, much more seamless, and once we do, it is likely that the same number of people can provide an awful lot more service."
A lot more services will be required in coming years. There will be a 60 per cent increase in demand for health services in this country by 2020, he says. "What I'm hoping to achieve is that we can provide the type of care that will be required over the next 20 years through the present workforce, and minimise the increases - and that's going to be a huge challenge."
The major reason people generally criticise the HSE and its structures, he believes, is because it is trying to change things. "Now is that to say we don't have problems? Absolutely not." He wants to fix the problems that exist, but "fixing them demands change and change is difficult and change in itself will at times challenge people . . . but change is what we have to do."
He stresses that, where quality and convenience clash when it comes to the provision of health services, quality will have to win out. This is why cancer services are being reorganised and why other acute hospital services will also have to be reorganised.
In the northeast, he says, it is still very much the HSE's intention to achieve, by mid-2009, a situation that would see all critical care and acute care brought onto two hospital sites - in Drogheda and Cavan. He denies Drogheda will need a huge increase in beds to accommodate services transferred from Navan and Dundalk. "We have to free up beds there by moving other patients and other work to other sites."
The northeast plan has met with opposition, and he expects protests too when plans are unveiled early next year for a reorganisation of acute hospital services in the mid-west (Limerick, Clare and north Tipperary) and the south (Cork and Kerry).
"They should be available to us early in the new year, and there's absolutely no doubt that, the same as in the northeast, we will be faced with very major challenges in terms of getting agreement to whatever is proposed, and I'm not party to what is proposed at this point," he says.
GETTING AGREEMENT ON a new consultants' contract has been equally hazardous. Harney has insisted the talks with consultants on new work practices must conclude by Christmas. The consultants say this is unrealistic. But Drumm backs Harney's stance. "I think deadlines are quite good, actually. I think we could go on and on and on and on but at the end of the day it's not unrealistic that we should reach deadlines and I think it's reasonable that they are set." But he acknowledges some "difficult issues" such as pay and private-practice rights still have to be agreed with the consultant representative bodies. "I remain optimistic," he insists.
He's not keen to discuss his own pay, however. Asked about the €80,000 bonus he got in September, within weeks of the recruitment ban being announced, he said he never took on the job for money.
"I really feel that I really do a tough job for what I'm paid . . . I could leave tomorrow, I can tell you, and I can guarantee you I could earn more doing a hell of a lot easier job."
But he has no plans to ditch the job just yet, insisting that he still loves the challenge it presents. "When I came here . . . I knew this was going to be a hell of a tough job. Is it a tough job? Absolutely. But am I going to give up on it? Look, in the end of the day Irish people need this health system transformed . . . Our vision is that we will provide easy access for people, that we will get public confidence in the system and that people will be proud to work in the system, and that was my commitment to people at the beginning . . . I'm not going to walk off without having done my damndest over five years to ensure that that's achieved."
ONE OF HIS key goals next year will be to tackle outpatient waiting lists. He discloses the HSE has plans to "set very definite targets" for outpatient waiting times and intends "to incentivise performance" by hospitals in this area. "This is one of the most frustrating things, for instance in primary care for general practitioners, who often find themselves having to refer a patient to A&E for admission to hospital because it is so difficult to get an opinion. And to be fair that's often due to the fact that maybe there are not enough consultants on the ground and we have to move to rectify those situations and we will be doing so very aggressively over the next year."
He also reveals the HSE has plans to open 860 new public nursing-home beds over the next 12 months, which should help ease delayed discharges from acute hospitals. The new beds will be in 13 community nursing units - five in Dublin (Clonskeagh; St Mary's, Phoenix Park; St Joseph's, Raheny; Cherry Orchard; and Palmerstown), five in Cork, one in Tralee, one in Galway and one in Limerick.
"These units will have very active rehabilitation facilities so that the focus will be constantly on trying, ultimately, to get you home," he says.
A new fast-track approach to construction has meant they will come on stream more quickly than would historically have been the case. Furthermore, he hopes a new GP contract can be rolled out. Negotiations with the Irish Medical Organisation on behalf of GPs couldn't take place up to now because advice received from the Attorney General stated that to agree fees with a union would be in breach of competition law.
"I am hopeful that we are now reaching a point where the Government will agree to a process that actually will allow us to move forward with rolling out contracts to GPs for their consideration in the relatively near future."
He also hopes the 100 primary-care teams that were meant to be rolled out this year can be put in place next year.But given the typically slow progress made on so many issues in the health sector, whether his wish list for 2008 can become a reality is anyone's guess.