Monday 19 March 2018

Drumm: politics of healthcare is holding us back

The former head of the HSE had a plan but he made slow progress in office, writes Maeve Sheehan

ADVISED TO MOVE SLOWLY: Former head of the HSE Professor Brendan Drumm. Photo: Gerry Mooney
ADVISED TO MOVE SLOWLY: Former head of the HSE Professor Brendan Drumm. Photo: Gerry Mooney

PROFESSOR Brendan Drumm is a model of old-school discretion. In the bar of the Westbury Hotel, he was modestly uncomfortable when photographed. He was chief executive of the Health Service Executive (HSE) for five years -- the volatile, vilified agency infested with more vested interests than the ploughing championships at election time.

So when he suggests that the job was tough, you can take it that's an understatement. There were anonymous letters, disapproval from some of his peers and he said he never went to functions expecting to be "the centre of applause".

His sons used to jokingly offer to be his bodyguards. "You could write a whole book on this, on how to survive in this type of environment on a personal level," he said.

Prof Drumm had what sounds like the job from hell. But he never thought of it that way. He was the HSE's first chief executive with a vision for much-needed reform of a recalcitrant organisation. He wanted an "integrated health service" with patients cared for in the community, overhauled hospitals, performances measured, medics calling the shots and consultants working 24/7.

What he got was an uphill battle, littered with cancer misdiagnosis scandals, bureaucratic breakdowns, cutbacks affecting some of the most marginalised, bruising clashes with public sector health workers and hospital consultants. All the while patients piled up on trollies.

As Prof Drumm said, he didn't go into the job to be popular. "I actually often ask myself how do politicians survive and I think they do because they've a particular make-up. I don't think I have that make-up," he said.

"I think they have a capacity to ignore criticism. I mean I could not ignore criticism. I would be dishonest if I said criticism didn't affect me -- it does affect me. I think what I was reasonably good at doing was parking it, putting it away some place where I didn't let it interfere with me on a day-to-day basis, and probably more than anything, I lead an extremely private life.

"I suppose that maybe, probably, was the way I survived it. Was that the right way? I don't know, but I lived and continue to live an extremely private life where I didn't engage outside of work in very many events."

The reason for Brendan Drumm's latest foray into the public domain is a book. Rather than writing his guide to survival at the top of the HSE, he wrote The Challenge of Change. He seemed a little taken aback when asked if there were any big revelations in it: "I hope it's not a book of revelation. If you wanted to buy a book of revelation I'd have written a very different book." But that is "not my nature", he added.

Instead, the book is a blueprint for the health service. It follows the, as yet, unfinished story of the transformation of the health service, initiated by himself, from local health fiefdoms in the paw of politicians to a streamlined, efficient structure of "integrated" healthcare.

In fact, the legacy of his time at the HSE is in laying the foundations for integrated care, rolling out the first primary care teams in communities, starting the hospital reconfiguration project and renegotiating consultants' contracts being amongst his achievements.

It's all there in the book. He wants the public to read it, as he says, to "realise that they pay for the health service in the same way that they do for other services" and that they must demand accountability from the doctors they pay for. They must insist on "seamless" care as they would if they were staying in a hotel, where 'sorry, the swimming pool is closed for lunch', doesn't wash.

If he felt so moved to write a book, then why didn't he try to stay on for another five years to see the job through?

He said he knew it was an enormously difficult job and he agreed with his family he would stick to five years. "I don't believe you should ever stay beyond your time in a job of that enormity," he said.

He joined in 2005, aged 48, to do a job that he estimated would take "a couple of decades" to complete. He thought it was "the right thing". The things that shocked most were the inefficiencies and waste.

There was no concept then of bulk-buying, for instance, even for incredibly expensive MRSI scanners.

There were political pressures. For instance, he was advised to "move slowly" in reconfiguring Irish hospitals by "practically every politician I met", apart from Mary Harney, the health minister who appointed him.

He was accused of conspiring with Bertie Ahern to build the National Children's Hospital on the controversial Mater Hospital site, in the then Taoiseach's constituency.

"The last man Bertie Ahern would pick, being a clever politician, the last man in Ireland he would pick to influence I suspect would have been me. He wouldn't have exposed himself to the risk of doing that," he said.

"I think the political system found me to be, and I am not saying it is a good thing, to be perhaps pretty rigorous in following our strategy irrespective of what the political imperative was."

He was adamant that the politics and a working health system didn't mix. For instance, a manager can't manage if every decision is being scrutinised for political impact. "You absolutely have to decouple politics as much as you can from the day-to-day operations of a health system," he said.

So was it galling then that the Health Minister Dr James Reilly has sewn the skirts of the HSE firmly to the coat tails of the Department of Health? On assuming office, he got rid of the HSE's board of directors and installed a new one replete with his department officials. Cathal Magee, Prof Drumm's successor, recently complained about Dr Reilly's ministerial advisers telling senior HSE executives what to do. "I wouldn't comment on what James Reilly or the Government do," said Prof Drumm. But it's clear from reading his book -- in which political interference in health is a recurring theme -- that he wouldn't approve.

His regrets relate to the slow progress of change. "I wouldn't have believed it would take two-and-a-half years to sort out a better deal across the pharmaceutical supplies; I didn't think it would take us over two years to negotiate new consultant contracts," he said.

He "would have loved to have walked out of there with primary care teams, at least their infrastructure, built in every place that was needed across the country." We have close to 50 and need some 200.

He believes the public is coming around to his vision of health transformation. He quotes the German philosopher, Arthur Schopenhauer: first it is ridiculed, then violently opposed, before finally being accepted as self-evident.

Hospital efficiency and performance management are now buzzwords. The jury is still out, however. For one thing, it's unclear how the health service will look in the future. Dr Reilly has pledged to abolish the HSE and is introducing universal health insurance, effectively a pay-per-item system in which money follows the patient, rather than blanket funding of hospitals.

Prof Drumm is back on his consultant contract and in the academic world of research and care in paediatrics. He wants to focus more on training people to be "superb carers", a skill he said was lost.

Maureen Gaffney, the psychologist who sat on the board of the HSE, apparently told him he was very "self-contained" -- which maybe helped him to filter the pressures of the job. "If everybody believes that you're following an agenda that's worthwhile, then I think everybody can survive," he said.

Despite suffering some bruising from a volatile five years, his commitment to his vision of integrated healthcare is undimmed.

He still believes the job was "probably, in many respects ironically, the best job anybody could ever aspire to getting in terms of the opportunities it presented".

"Equally, this was also a job which was very complex but overall it was a marvellous opportunity."

His public service stint is done. "I just don't see too many cases out there where I would see myself engaging again. There is a danger that you over impose yourself and I think I have had my shot."

History will no doubt issue its own verdict.

The Challenge of Change, by Brendan Drumm, Orpen Press

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