Health reform is impossible until managers can be held accountable
The heated exchanges between the HSE and the Health Information and Equality Authority (Hiqa) regarding the latter's report on the pattern of infant deaths in Portlaoise Hospital highlight a matter of the utmost importance - the accountability of senior managers when things go wrong.
Enquiries into calamitous institutional failures and individual tragedies have commonly focussed on the part played by the front-line staff, to the exclusion of senior managers and boards. So, for example, a report last year into the death of Savita Halappanavar in University Hospital Galway found that of the 30 staff "directly involved in her care" nine had a case to answer for, while 13 "missed opportunities" to prevent the tragedy.
If 13 opportunities to prevent a tragedy are missed then the root cause is not simply human error or individual incompetence. This is evidence of a "systems" failure. But if it was a systems failure, then who was responsible for the design, implementation and maintenance of systems? And the answer is: managers at different levels and possibly board members, senior civil servants or the relevant minister. It is they who are responsible for such elements of the system as the structures of accountability, safe and efficient care pathways, compliance with 'best practice' clinical protocols, training, adequate funding and legal frameworks.
The exclusion of those whose job it is to ensure good systems explains why Praveen Halappanavar continues to say: "I still don't know who is responsible for my wife's death." Nor would the public ever know what caused the sequence of deaths in Portlaoise if these actors were excluded.
The Hiqa report, which makes 250 "adverse findings" against senior HSE officials and civil servants, will inevitably have implications that reach beyond Portlaoise Hospital, to the extent that these findings stand up. The closer to the apex of an organisation that any weaknesses exist, the more widespread the fallout. In resolving the dispute between Hiqa and the HSE it is imperative that two features of the report must not be diluted - the range of corporate functions cited as contributory causes of the pattern of infant deaths and the identification of managers and officials allegedly responsible.
Whatever the inherited legal constraints, it is vital that a way be found to hold individuals personally accountable in this and similar cases. Without personal accountability there can be no personal consequences and when there are no personal consequences then the same failure inevitably recurs. When Dr Tracey Cooper, who was CEO of Hiqa, left office she said: "When something goes wrong nothing really happens... the problem is we have never seen any consequences... if there are repeated failures nothing really happens... we have not yet cracked accountability."
This was the scenario in Portlaoise until very recently, when some remedial steps were initiated, but only after exposure on RTE's 'Prime Time', and in the Halappanavar case. Two years after Tania McCabe died from similar causes and after new protocols were specified for the management of sepsis the majority of maternity units around the country had not yet implemented them. Who was responsible for this failure in implementation? Not those "directly involved in her care".
Last Thursday, the Irish Independent reported that no senior manager was among the 16 staff suspended in Áras Attracta on foot of an RTE programme that showed vulnerable people being force-fed, slapped and kicked. Six months after these revelations and following HSE promises to implement reforms, Hiqa found just patchy implementation.
On taking office the Government talked in ringing tones about "the huge accountability gap", that "we will pin down accountability for results at every level from ministers down - with clear consequences for success or failure… new guidelines will be introduced for civil servants that reflect the authority delegated to them and their personal accountability for the way it was exercised".
Until there is a regime that pins down personal accountability, with consequences - especially for senior people - then we are fated to see the same tragedies and scandals repeated in all sectors, be it the health service, food safety, banking and other white-collar activity, the planning system, building standards, nursing homes or children in the care of the State.
The Irish philosopher, Philip Petit, in his book, 'Just Freedom: A Moral Compass for a Complex World', explains the difficulty citizens have in extracting the truth and securing justice from institutions of the State, such as the HSE. The State has three advantages: bottomless pockets, endless patience and anonymity of officials. Recall the battle between abuse victim Louise O'Keeffe and the State or the families we see every week outside the Four Courts worn out after a 10-year battle to get justice.
The Hiqa investigation into Portlaoise Hospital has broken new ground by including within its scope the role of those who are responsible for ensuring that front-line staff are provided with well-designed, adequately funded and rigorously-governed systems. Crucially, this report has confronted the culture of anonymity and consequent impunity for senior managers and officials. Unless there is transparent, personal accountability, with consequences, nothing will ever change. It is vital, therefore, that Minister for Health Leo Varadkar vindicates the right of Hiqa to carry out its role without fear or favour, with invasive scrutiny and effective sanctions.