A visitor to Ireland would conclude that we are obsessed with health, which isn’t true. We are unusual in the amount of front-page coverage of health care failures. This reflects the extent to which our health service is an extreme outlier among European health services. The majority of the other EU systems, mostly just work; ours, mostly, just doesn’t.
One striking feature of our health service is the mismatch between authority, responsibility, and accountability. In effect, no-one in a position of authority can be confident that they will be supported if they challenge those whom they direct for failing to deliver. Equally, there is little consequence for the most extreme failures, even when these failures become public.
Reading the reports of repeated failures in our hospitals, and other facilities, this becomes very clear. At an extreme we get an Áras Attracta, where despite the most inexcusable actions, no-one beyond those staff directly involved, has yet been publicly held to account.
A more common problem is that people can ignore HSE policies, and effectively refuse to deliver in their roles, without consequence.
Sláintecare holds out the best hope for the future. However, it's fair to ask if the HSE can drive the changes needed to bring it about
This was evident in the cervical cancer scandal, where a clear policy of the organisation, on open disclosure, appears to have been ignored, so far with no apparent consequences for those who ignored it. A somewhat similar problem arises with the minority of consultant staff who abuse their contracts. Too many managers in HSE have heavy responsibilities, but no authority, and cannot hold their staff accountable.
Modest changes
There are patches of world-class practice, with astonishing innovation, but these almost never roll out across the organisation. Even more modest changes, e-prescribing, for example, can take years longer than necessary to deploy. There is little capacity to make change stick, and too many people who can simply refuse to change, and know that they will get away with it. This is a symptom of a very bad culture, and very poor governance.
Sláintecare holds out the best hope for the future. However, it’s fair to ask if the HSE can drive the changes needed to bring it about. For Sláintecare to work, care has to shift from expensive, undifferentiated, and overcrowded acute general hospitals to a mixture of more specific inpatient facilities, and many more community services. This will require resources, but it will also require better governance, and a better culture.
At the moment, it seems that neither the Department of Finance, nor its Minister, believe that this will happen. From their perspective, the HSE has overrun its budget almost every year since it was set up, partly because the budgets were unrealistic, but partly because it is so resistant to change. Health is seen, not entirely fairly, as a black hole for State money.
Sláintecare is the strategic direction, but the answers to the other questions are unclear
The first goal of the Sláintecare implementation strategy is “to deliver improved governance and sustain reform through a focus on implementation”. The HSE needs much more effective governance, and a much better corporate culture. Culture change has started, slowly, and after a lot of work. The culture is still closed, and secretive, but it is beginning to open up. This change may be working better for front-line staff than middle managers, but it is happening.
Little clarity
There are several governance holes in the HSE. At the centre there is little clarity about who is responsible for what – where are the real boundaries between the Minister, the civil servants, and the senior management team in the HSE? Governance is about direction, but it’s also about responsibility, authority and accountability. Sláintecare is the strategic direction, but the answers to the other questions are unclear. Further out, the HSE is still a series of silos, many dating from the time of the health boards, and these are managed, often with little sense of how they fit into the wider purpose of the Irish health service.
These holes have to be filled. Having a Board is necessary, but not sufficient. The HSE had a Board previously, and that worked very poorly. If this is not to happen again, the members will need full support from the Minister, and an utterly clear demarcation between their responsibilities and those of the Department. They also need to be appointed soon, to choose their own CEO, revamp the senior team, and move on to changing the HSE. Without all of this, they might as well stay home. The senior team then need to be supported to get on with improving the culture, breaking down the silos, bringing in more rigorous governance, and changing the HSE into a workable organisation.
Without these changes Sláintecare will fail.
Anthony Staines is Professor of Health Systems at Dublin City University