The emails pinged into my inbox in perfect slick co-ordination. First the “heads up” press release from the Health Information and Quality Authority (Hiqa) about the imminent publication of its independent statutory review into specific orthopaedic cases and governance in Children’s Health Ireland (CHI), including at CHI Temple Street.
Then, just 30 minutes later, the actual report and executive summary, more than 200 pages outlining the failures that led to non-CE marked metal springs being implanted in three children during treatment for scoliosis of their spine. This was swiftly followed by statements from the HSE, and the Minster for Health, accepting its findings and apologising to those affected and, shortly after, the resignation and apology of the chair of the CHI board, Dr Jim Browne.
[ Spinal surgeries report: The story behind the springs used on childrenOpens in new window ]
Job done. Boxes ticked. Head on a plate. Solemn statements and pithy political responses. Shocking and unacceptable. Very sorry, won’t happen again, already implementing the recommendations, and so on.
But of course, something like this may well happen again. At the heart of the problem lies a labyrinthine system of governance and care delivery, not only in CHI, but across our entire health service.
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A key focus of last week’s Hiqa report was the many, many failures in corporate and clinical governance in Temple Street and CHI, and the confusing and convoluted management and reporting structures.
CHI and its board were set up to manage the merging of our existing children’s hospitals into the new €2 billion-plus (potentially the world’s most expensive hospital) new national children’s hospital, which Hiqa described as “probably the biggest change-management project in the entire country at this time”.
In its report last week Hiqa noted that CHI’s changes to the existing hospitals’ organisational structures led to unclear lines of reporting, accountability and oversight across the organisation. The governance structures and management arrangements at CHI were overly complex and did not enable effective management and oversight of the orthopaedic service at CHI at Temple Street.
This criticism could apply to the health service as a whole.
We have a very confusing, convoluted healthcare system in Ireland, a unique mix of public, private and “publicly funded” providers that operate in a fog of overlapping roles and mandates. The Department of Health sets policy and the HSE implements it, and the various independent regulators provide a watchdog role. In theory, anyway.
In reality, it is often unclear who is ultimately responsible for performance, outcomes or even basic service delivery in many areas of the system, not to mind who is accountable or who has the power to intervene when things go wrong. And our health service is far from transparent on the nitty gritty of exactly how it operates.
So called “voluntary” hospitals, many set up by religious orders or private bodies, receive the bulk of their funding from the State. However, they are independent of the HSE and have their own boards.
Despite tightening-up of service-level agreements and streamlining of certain services and posts to come more in line with services owned and run by HSE, the voluntaries have resisted what they see as heavy-handed attempts to rein in their independence and an ethos that has previously clashed with the State on various issues. The result is that there remains considerable blurring around accountability and autonomy between the HSE and these hospitals in many areas.
The HSE – which is itself governed by a board that reports to the Minister for Health – came into being just over 20 years ago, replacing the previous health board system with lofty promises of a modern national healthcare service that would eliminate geographic inequalities under the old structures. The HSE had hardly settled into one incarnation when it was moved into another – swiftly going from centralised everything to 32 local health offices operating within four administrative areas, and then to the again much lauded hospital groups – and it is currently bedding down into six new health regions, which will be responsible for providing both hospital and community care in that area.
As one health service insider noted, we are constantly either centralising or regionalising and each iteration is fervently promoted as the answer to our problems. But it’s not. Because the underlying issues of clear governance, accountability and reporting structures in our health services are never properly ironed out and fully implemented.
The many different boards in each new healthcare structure take time to bed in, and as is becoming increasingly, worryingly clear, many people with the vital expertise and experience just don’t want to be on these boards any more. And can you blame them? For just up to €12,000 annually, growing responsibility and pressure, who would risk the potential for reputational damage when things go wrong?
Since the Covid-19 pandemic, our health service has seen a very significant increase in funding and staffing, alongside ongoing advancements in medical interventions and changes in the delivery of medicine, and increased demand from our growing and ageing population. Coupled with our adversarial medico-legal environment, also in desperate need of faster reform, is it any wonder that healthcare boards, and key leadership roles, are struggling to attract or retain high-calibre candidates?
And existing management within our healthcare organisations is also struggling to adapt to the ever-changing structures. As CEO and manager and clinical director roles change in scope and responsibility, who is overseeing those changes, bedding them in, and making sure they are actually working? Sometimes the post holders themselves are not quite sure what they now can or can’t do and who and what they are responsible for. This is simply not acceptable. And quite obviously puts patients, and staff themselves, at risk.
HSE chief executive Bernard Gloster said last week that he will request an early meeting with the board and executive of CHI “to set out our clear expectations in all matters of governance and oversight”. But what are those expectations? Who is responsible for doing what exactly? And will anyone actually tell us, the patients, healthcare staff, the taxpayer?
When no one is responsible, no one is accountable, and shocking incidents like what Hiqa’s latest report outlined – just one of a number of serious issues being investigated in the paediatric orthopaedic department in Temple Street – are likely to happen again.
Priscilla Lynch is clinical editor of the Medical Independent and a freelance healthcare reporter who completed a fellowship in health innovation journalism with the International Centre for Journalists last year
