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What the hospital scandals teach us about management


Health Minister Leo Varadkar at the Midlands Regional Hospital, Portlaoise. Photo: Collins

Health Minister Leo Varadkar at the Midlands Regional Hospital, Portlaoise. Photo: Collins

Health Minister Leo Varadkar at the Midlands Regional Hospital, Portlaoise. Photo: Collins

In sharp contrast with their efforts to forestall publication of the Health Information and Quality Authority report on Portlaoise hospital, the Health Service Executive recently published for all to see the results of a staff survey, entitled 'Have Your Say'.

Not surprisingly, external criticism of HSE senior management is echoed in staff ratings of the people who run the organisation. For example, only 9pc of staff agreed that "change is well managed within the health service" and just 12pc "have confidence in decisions made by senior management".

Some credit is due to the HSE for publishing this damning picture, the main focus of which was on aspects of how people are managed, for example, training, career opportunities, communication, stress, teamwork and working conditions.

However, the HSE has never been so transparent about serious and persistent failure in the management of money or, most vital of all, in the management of patient care, their core mission.

With regard to catastrophic failures in patient care, countless investigations have focussed almost exclusively on the front line staff involved in each incident and concluded that the death or injury was due to a "systems failure".

This deceitful strategy leaves managers, whose job it is to install effective systems, off the hook and, in this context, the report into infant deaths in Portlaoise, by highlighting the failures of senior hospital and HSE managers, represents a major breakthrough.

The problem with HSE management starts at the top. There has never been stability at the apex of the organisation because of constant chopping and changing in governance and organisation structures.

Newly appointed CEOs were never given the authority they needed to choose their own team. They had to create a team from the pool of officials already in situ.

To overcome this problem one chief executive, Prof Drumm, brought in his own kitchen cabinet from outside, which created its own difficulties. Key positions commonly are held by people in an "acting" capacity.

From the outset, the Department of Finance put a cap on the number of staff allowed at senior grades, further limiting the chief executive's choices.

Offering a salary of €150,000-170,000 to attract a person capable of managing a €13bn budget and less than that for a HR director of an organisation employing 120,000 very diverse staff, is typical of the short-sighted constraints placed on the HSE.

This is no disrespect to anyone who has filled these slots, but institutional reform from within, by incumbent, long-serving management teams, is very rare.

Attempts to bring in new blood such as Tom Keane from Canada and Aidan Halligan (who died recently) from the UK faltered, I believe, because of these and other, largely political, constraints on what they knew needed to be done. They were not willing to take on such a hugely-demanding task with hands tied behind their backs.

There are six essential elements to a functioning management system: management skills, management processes, management information, management tools like effective HR policies, an effective performance management system and proper management structures.

Very briefly, many people holding senior executive positions in the HSE do not have the necessary training for those positions, that is training in the management of operations, money, people, risk, implementing change and strategic planning.

Management disciplines, that is routine processes of short-term and long-term planning , review-control, reporting and good governance are patchy.

Large areas of the HSE have neither the measurement templates nor the IT systems to provide local managers with the information they need to manage people, money or patient care or to enable senior managers to exercise oversight.

It is only a few months ago that the chief medical officer, Dr Houlihan, was able to publish, for the first time, the numbers of people who died in our hospitals.

HR policies are such that managers will tell you they are powerless to deal with people who ought to be sanctioned even for quite serious reasons.

It can take six months to replace a nurse through the shared HR services centre in Manorhamilton.

There is no effective performance management system for managers. Management structures are in a state of constant flux; many managers don't have the delegated authority they need to do their job; and some support functions are too centralised.

Compared to the HSE, the hospitality industry in Ireland has a better system for the training and cultural formation of hotel managers, sending them to the best hotels around the world on a carefully structured development programme. The results speak for themselves.

With these defects in the management 'infrastructure', even well-trained managers have difficulty managing.

Consequently, they spend much of their time just reacting to endless problems, rather than managing in a purposeful way.

It is not a case of too many managers in the HSE, as often alleged, but rather of too many people with a management title who are not managing.

They spend their time 'shooting crocodiles' when their job, especially at senior levels, is to 'drain the swamp'.

These same deficiencies are common in the wider civil and public service with people reaching the very highest levels with little or no management training, non-existent management disciplines, weak performance management and so forth.

A case in point is the Department of Justice and Law Reform, slated in a recent report for having virtually no management system. The Department of Public Expenditure and Reform published plans earlier this year to address this endemic problem.

The HSE needs its own separate plan. Hopefully, the hard-hitting messages from their own staff and the HIQA report on Portlaoise, which indicted senior echelons of the HSE and the Department of Health, will prod the powers that be to map out and implement a comprehensive, adequately funded programme to strengthen the management systems of the health service from top to bottom. It would be money well spent and patients would be safer.

Dr Eddie Molloy is a management consultant

Irish Independent