HSE needs cash - but that won't fix management crisis
It is widely reported that Health Minister Simon Harris and members of the Fine Gael parliamentary party have declared war on HSE managers, threatening to remove those who do not measure up. While conceding that more money is needed, they contend that the root of the problem is managerial incompetence.
In the past six weeks, if ever it was in doubt, it became abundantly clear that the HSE is not sufficiently funded to provide a quality, safe service. Just for example, estimates of the numbers dying every year in a dysfunctional A&E are put in the hundreds and one in every eight of the population is waiting more than a year, while they endure intolerable suffering to see a consultant.
Significant additional funding is needed just to keep a threadbare, dysfunctional service operational and coping with growing demand, until such time as the whole system, which everyone agrees is not fit for purpose, is transformed.
In a recent 'Sunday Business Post' article, HSE director general Tony Mr O'Brien spelt out the cost of such comprehensive reconfiguration and reform. Some €9bn will be needed to create a service that will deliver timely access based on need rather than ability to pay; high quality, safe care; good health outcomes; and value for money. It is not clear if this figure includes the latest estimate for the National Children's Hospital of €1.2bn, which Mr O'Brien says is unaffordable, given the other pressures on the HSE's already planned capital programme. For example, 9,000 pieces of old or at risk equipment needs to be replaced and ambulance services are in crisis.
The HSE needs an injection of additional money in the short term to mitigate widespread suffering and untimely deaths. But starting in next October's budget it will also need some of that €9bn to begin work on the longer-term transformation programme that will be recommended, hopefully, by Róisín Shortall's all-party committee on the future of our healthcare system. The longer such root and branch reform is delayed, the longer the human and economic cost of lengthening waiting lists and A&E chaos.
So, it is about money and lots of it but, that said, Mr Harris is quite right in his determination to tackle managerial failings. Scores of enquiries have exposed grievous failings across the health service in our hospitals and community care settings. But before the minister goes after any individual, intent on removing him from his role, he needs to exercise caution because the fundamental problem is not weak managers per se, of whom there are quite a few, but the absence of a management system.
There are several elements to a management system, that is the supporting infrastructure that any manager needs in order to carry out their role. They have to be trained in management, including how to manage people, operations (ie work flows), budgets, risk, change and culture. There is no standardised training requirement in these competencies for either 'lay' or clinical managers in the HSE before they take up a management position.
Managers need information at their finger-tips to know what is going on in their area in regard to patient access, care, safety and outcomes; in regard to overtime, absenteeism, and other HR measures; and in regard to capacity utilisation, money and all other aspects of their area of responsibility. They need this localised information in order to plan, execute and control; to drive continuous improvement; and to underpin accountability. The HSE does not have these basic, joined-up management information systems across the organisation.
Organisation structures specify objectives for which a manager is accountable and the authority he/she has to make particular decisions. There is much blurring, from the minister, through the Department of Health and the apex of the HSE and right down both the clinical and managerial chains of command to the front line, as to who is responsible for what.
Managers may have clearly specified responsibilities on paper but their authority is often not accepted by those over whom they are supposed to exercise that authority. I once complained about a clinician to his national clinical lead, who told me this was not the first complaint he had received but that he was powerless to do anything about it. I could go to the Medical Council if I wished. In another case, wishing to maximise the use of operating theatres, a manager asked a surgeon, a heavy user of theatres, for the dates of his holidays and he was told "it's none of your business".
Every functioning organisation needs an effective performance management system, one whereby managers have to explain and justify their performance, with the implication of consequences arising if they fail to perform adequately. This is the kind of process Mr Harris would have to rely on if he tries to fire or otherwise penalise an underperforming manager. However, such grown-up performance management systems are notable by their absence across the public service, especially in the health service. Two years on from HIQA's serious criticism of several levels of management in its report on infant deaths in Portlaoise Hospital, the HSE has conceded it does not have either the legal or HR tools to hold managers accountable. Hard to believe, but true.
Reports that the performance management system now being contemplated will have no provision for sanctions like sacking or pay cuts will make a bad situation worse. It will be farcical. A move sideways into a less demanding job on the same pay represents a reward for underperformance, not a penalty.
The absence of an effective system of accountability breeds a culture of impunity and no one can deny that is what we have had in many parts of the hospital and social care services of the HSE. However, if the Health Minister was to go after any manager who has not performed, he could well lose any subsequent court case on the matter.
In spite of these systemic deficiencies most HSE managers do a remarkably good job, but these deficiencies also mean even the very best are forced to spend far too much time fire-fighting rather than managing and also help to explain the extraordinary proliferation of staff with the title of manager.
Eddie Molloy PhD is a management consultant