Those at the top can't be exempt from scrutiny
If a failure is systemic, then those in charge of the system must accept their share of responsibility
The latest enquiry into the death of Savita Halappanavar in University Hospital Galway, concluded that, of the 30 staff involved in her care, nine had a case to answer, and they were subjected to disciplinary sanctions. It had already been reported that there were 13 "missed opportunities" to intervene to prevent the unfolding tragedy.
I highlight staff involved in her care because, if you have nine people missing a total of 13 opportunities to do the right thing, this clearly points to a systems failure and - whether or not front-line staff are singled out and sanctioned for their individual failures - as in this case, once there is any hint of a systems failure, it imperative to address the question: who is responsible for ensuring that proper systems were in place, and what sanctions ought to apply to them?
There is more than a hint of a systems failure in another case - that of the young asylum-seeker, whose baby was delivered at 24 weeks, after she was refused an abortion.
The HSE enquiry found that she had been placed on an appropriate "care pathway" at the outset and that staff, who had cared for her, had "acted in good faith". Opportunities were missed, however, and this was caused by the "lack of coordination and protocols for sharing information" among staff from the HSE and other agencies who encountered her along her care pathway.
In general, managers are responsible for ensuring there are proper systems in place. That is their job and what they are paid high salaries to do, yet, it is common in Ireland to exclude from the terms of reference of enquiries into scandals or catastrophic events, the role of the most senior managers, boards, civil servants and politicians. As a result, the top brass, who have a more serious case to answer than front-line staff when there has been a systems failure, escape any consequences.
The substantive work of management involves working on the business, as distinct from working in the business , which is what front-line staff do, be they nurses, lab technicians or porters .
Working on the business entails such tasks as installing 'best practice' procedures at each step in a care pathway and, crucially in healthcare, ensuring efficient and effective hand-over routines from one unit to another.
Other vital management work includes monitoring compliance with these disciplines, ensuring staff are adequately trained for their jobs, clarifying the spinal cord of personal accountabilities from top to bottom, building a culture of excellence and so forth.
You need training to do this stuff, but across the health system there is no organised programme of management development, tailored to equip people as they move up through the chain of command. In particular, scores of medical consultants have been appointed to executive roles in all specialisms. These medics, whose expertise is in working in the business, receive insufficient management training, even though they may be responsible for multimillion euro budgets and hundreds of staff, delivering complex services.
Apart from deficits in management expertise, in large areas of the service, the information and other tools that managers need in order to do the job are inadequate. Dr Tracy Cooper said, on leaving her job as CEO of HIQA, "we don't even know how many people we are killing or injuring in our health service".
An estimated €78m is needed to bring the financial information systems up to scratch. The HR tools that managers need, for instance, to confront and deal with poor performance or high absenteeism are too weak to create a deterrent effect.
A third unresolved weakness in management systems, that is particularly prevalent and damaging in the health service, is the pervasive resistance among staff from a particular medical, professional or administrative grouping to allow themselves to be managed by someone from another background, or even by a member of their own profession. In one instance, a manager responsible for containing costs and maximising the use of operating theatre capacity was told by a surgeon, a heavy user of these facilities, "when I take my (three weeks) holidays is none of your business".
As a result of this endemic problem, managers end up being mere 'coordinators', administering as best they can, but powerless to effect change. They are given lots of responsibility but not the full delegated authority to do the job. This vexed issue has largely been resolved in other countries.
A fourth common problem is that clinicians, who carry dual management and clinical workload responsibilities, find themselves having to defer necessary work on the business because an acute shortage of resources forces them to prioritise their work in the business, caring for patients.
In both tragedies mentioned here, senior clinical and general managers must not be exempt from scrutiny. Specifically regarding the Halappanavar story, which occurred two years after Tania McCabe died in similar circumstances, and after new protocols for sepsis management were issued, a large proportion of maternity units had not yet implemented them, including UHG. And since there were no consequences for this non-implementation by managers or boards across the wider health service, it is no surprise that last week, two years further on, it was reported that only one out of 39 hospitals ranked itself "excellent" in regard to recommendations made on foot of Ms Halappanavar's death. This is a serious managerial failure.
All investigations into serious failures should include an obligatory section on the role of those involved in management and governance, and this should apply in all sectors, not only in health.