Tony O’Brien, Director-General, Health Service Executive (HSE)
As you will have heard in the introduction, I have been at the head of the health service for almost 5 years. But what you may not know is that this is a job that I never actually asked to do. I didn’t apply for it like you do for most jobs. Instead I received “an invitation” from the Minister of the day back in 2012. Now you may find it interesting to note that I spent the 5 years, previous to taking up this DG role, doing my utmost to keep the National Screening Services (which I was running at the time), out of the HSE.
And you probably also don’t know that I only accepted “the invitation” because the principal task was to oversee the abolition of the HSE and to move away from centralised control across the vast number and diversity of services, and towards a model that involved greater devolution of decision-making, responsibility and accountability to the frontline services. That is what we are attempting to achieve today through the embryonic Hospital Groups and Community Health Organisations. Why am I telling you this? I am telling you this because part of the title of today’s discussion refers to “OUR DYSFUNCTIONAL HEALTH SERVICE”. Of course this is a headline or comment that we hear and read so often.
I want to be clear with you from the outset that, while I was never a great fan of the HSE concept, I disagree with the populist and simplistic sentiment that our entire health service is dysfunctional. Despite my views on where the HSE came from, today I applaud and defend the great work done by both the organisation as a whole and the individuals who, for the most part, work unselfishly delivering care.
THE FOCUS ON NEGATIVE OUTCOMES
What is often forgotten in certain elements of media coverage, political debate and interest groups [often self-serving narratives], is that the greater majority of the health services delivered in this country today is of a very high standard. A much lesser minority of services could justifiably fall into the “dysfunctional” category as, I would be the first to admit, is not of a sufficiently high standard and in some instances quite poor. There are many reasons for this. Unfortunately, in the rush to focus on the negative outcomes, the great work undertaken by clinicians, allied health professionals, administrators, managers and many others rarely gets a mention.
So why can we not get the minority of underperforming services correct after so much effort and so many attempts over the years. The reasons are multiple and diverse and I could use up this entire evening discussing these. For example, I could discuss how today we are still playing significant catch-up following decades of underinvestment in health, and in particular over the last 6 years during the austerity period. I could describe how a lack of national integrated systems, including electronic health records, HR systems and financial systems, prevent us from having sufficient control over many of our important business transactions and records management. I could discuss that we attempt to operationalise a health system where the people who work in it had little input into its design, have little influence over the funding levels provided on a yearly basis and whose inefficiencies are not the result of their decisions but rather due to an absence of decision making, of making hard decisions over generations. Other topics that could be of interest during tonight’s discussion include our mismatch between supply and demand – how our year-on-year increase in demand for services is far outstripping the financial resources provided to supply these services. Also, I could have included the outrageous prices charged by some pharmaceutical manufactures for high-tech drugs that is eating into our ability to provide other vital services. However, these are discussions for another day. I will touch on some elements of this later in this talk.
This evening – with the time that I have available to me – I wish to propose and discuss two specific areas of concern:
OUR HEALTH SERVICES MODEL IS NO LONGER FIT FOR PURPOSE
When I contributed to the Future of Healthcare Committee at the tail-end of 2016, I argued that our health services model and design, as it currently exists, is no longer fit for purpose. It was designed for a time when we had a different demographic profile and the expectations around clinical governance and standards were not as they are today. Today our population is older. Modelling forecasts tell us that the over-65s will increase by nearly 110,000 in the next five years. That is great news and a great reassurance, I’m sure, to most of us in this room tonight. However, the bad news is that a large proportion of this older age group now lives with two or more chronic conditions, which make many of our older citizens more vulnerable and frail. We see the impact of this in our Emergency Departments with many reporting a 12% increase in the over-75s being admitted to hospital through our EDs, which is a significant factor (not the only one) in our ED overcrowding. For example, the local 24/7 Emergency Department in Letterkenny General Hospital reports a 14% increase in elderly and frail patients when you compare May ’16 to May ’17.
MORE PRIMARY-CARE FOCUS
There is no doubting that many of our elderly and other cohorts of patients who now depend upon the acute hospital setting could be treated far better and far more appropriately in other settings – such as Primary Care and where possible at home. It would surely be better for them and cheaper for us. So, you may ask why is this not happening?
Over the past year I have discussed the “decisive shift” that is required in order to shift from an acute hospital to a more primary-care focus. A shift such as this requires us to build capacity outside of the acute hospital sector in order to allow us to adequately manage chronic conditions. It also requires us to move services such as diagnostics, assessments and certain procedures that are currently provided in acute hospitals, to the community setting. However, in order to achieve this successfully, a significant transitional fund – which lies outside of the normal health budget – is an absolute requirement. This will ensure that services can continue (and in some cases increase) while we build our primary and community care services to the required capacity and standard.
DEVELOP CENTRES OF EXCELLENCE
We also need changes to occur in our acute hospitals. Our health system since the 1950s has been very hospital centric. The culture has long been if you are sick you go to A&E or EDs as they are now more properly called. That brings you straight into the acute hospital setting – the most expensive part of our health system by a mile. We need to streamline the services that we provide in the acute hospital setting, eliminate unnecessary duplication of services in hospitals within close proximity and instead continue to develop centres of excellence. In some smaller acute hospitals today – for historical reasons – we see complex trauma care and other complex procedures provided in a situation where, from a clinical safety perspective, this should not be happening.
It is also important that we regularise our governance arrangements with the voluntary hospital sector. While the HSE is the majority funder of all voluntary hospitals, there is an expectation by the Public Accounts Committee and other bodies that we somehow “control” how these hospitals manage their affairs and comply with different government policies. However, recent media coverage has shown that the voluntary sector has a different view in terms of our role. This not alone creates inefficiencies but also unnecessary tensions between organisations that need to work closely and with collegiality. I welcome Minister Harris’ establishment of a formal review to examine the future role of voluntary hospitals.
MAKE HARD CHOICES FOR CHANGE
In addition to reforming the acute hospital system, it is equally if not more important that we enhance the range of services we provide in the community through our GP and Primary Care services. This is particularly important for dealing with chronic conditions especially for the frail elderly. Furthermore, we need to change the culture of the population who tend to use the acute hospital system as their default choice when they first need health services.
If we don’t do this and keep doing what we are doing currently, we are most likely to see costs spiraling out of control due to inherent and historic inefficiencies in our system today – some of which I have mentioned earlier. In the longer-term, we are likely to see a perverse result in that we will spend much more as a result of these inefficiencies than any investment or “transitional fund” required to transform to a more efficient system.
Taking much of what I have just discussed into consideration – in the absence of a collective societal and political willingness to make some of the hard choices required for change – I question whether it is possible that we can ever achieve a health system that can be truly operationally efficient, that can provide effective value for money, and can provide a world-class care in health delivery and outcomes.
A number of years back, I had the privilege of working alongside Prof Tom Keane in the design of the implementation of the Cancer Strategy. A lot of unpopular and hard decisions were made at that time. As I am sure you all remember, they were hard fought and strongly resisted. And for the record, Co Donegal was not hiding in the shadows in this fight. However, ten years on, while the hard decisions were not to everybody’s satisfaction, I am sure that nobody would want to go back to where we were. And the reason nobody should want to go back is that those hard choices have led to better health care and outcomes for most forms of cancer.
POLITICAL COURAGE IS NOT OFTEN APPARENT
Attempts to tackle much of what I have discussed earlier, including stopping some inappropriate services in smaller hospitals and centralising care in other parts of the health services requires a type of political courage that is not often apparent. As the truism goes – all politics is local. To be seen not to oppose what is perceived by many as “cutting” a long-standing local service is not viewed as a great vote getter, regardless of the clinical risks that retaining the long-standing service might pose. Society as a whole, all of US, have an important role in all of this. Voters have an opportunity every five years or so to REWARD politicians who take the time to read the available clinical evidence and who support hard decisions (regardless of how unpopular they might seem) in the interests of having better and safer health services.
Those who drove here from Dublin passed not too far from Roscommon Hospital. This was an acute hospital that was providing a range of complex surgery and trauma care in circumstances where the clinicians in the hospital themselves questioned the safety implications. As I am sure most of you remember, we ceased providing that type of complex care and changed the role of the hospital to a more appropriate and thus safer service. This was undertaken while balancing a number of inter-related considerations including clinical risk, the economic impact on the local area and the maintenance of appropriate jobs for the hospital staff. In the background was a vitriolic campaign by some local people; polarised views arose resulting in much heated debate and protest. Some politicians were ostracised, others used the controversy to raise their profile. Today Roscommon Hospital flourishes – providing less complex procedures, but providing considerably more, and badly needed, outpatient services, day surgery and diagnostic services to the people of Roscommon and its environs. So, the sky has not fallen – despite the prophesies of many at the time.
The Slaintecare Report provides an ambitious vision of a different kind of healthcare system. It can only be delivered if a number of hard choices are made. I am optimistic that the ability of the members of the Future Healthcare Committee to agree on consensus is a very good starting point.
Just before I move onto my second point, this first section on the current construct of the health services (and closely related to the subject of hard-choices) is the requirement for an understanding that individual tragic cases will always exist and gain considerable prominence in the health care environment. I do not for one second want to trivialise the grief and distress experienced by many families when these cases occur. While we must improve the standards of our services based on lessons learned from individual tragic cases, we should not however, develop policy and the future of world-class services based on these cases. Instead, future health services should be based on the best available clinical evidence and experience – just as we did with the Cancer Programme.
At the outset I mentioned that I would touch on two of many reasons why some of our healthcare delivery is not to the standard that we would all like it to be. I would like to spend a few minutes touching on a much-debated topic.
AUTHORITY AND RESPONSIBILITY
When things go wrong in the health and social care environment, the public demand – and rightly so – that people are held to account if they have transgressed. There is abundant evidence that vesting authority, empowerment and responsibility as close as possible to the delivery of care produces better outcomes. With this authority and responsibility devolved to a more local level will come real accountability and the ability to hold the appropriate person or persons to account for their actions or inactions.
However, being able to hold the appropriate person to account in the health services is fraught with difficulties for a number of reasons – particularly our long-standing and at times quite constraining disciplinary process that we are obliged to follow rigidly. Recent High Court decisions concerning very high-profile cases have supported long-standing processes, agreed with representative bodies, that PREVENT us from circumventing any agreed processes surrounding our disciplinary processes – regardless of the outrage expressed by the public, media and politicians. Long drawn-out disciplinary processes often lead to us being accused of “never holding anybody to account”. In the absence of “a person” to whom we can readily point to and say: “following our disciplinary process we conclude that this person is responsible” what happens instead is that those at the very top of the health services become the targets.
There has been for too long a farcical ritual of the Minister of the day being “held accountable” for every operational level event or decision made anywhere in the health and social care delivery system, even at the most micro level. This inevitably drives a perverse behaviour among politicians and civil servants who are almost forced to drive an unavoidable top down/micro-managed approach to management. This approach then tends to pervade the entire system.
As you can imagine, the effect of this is of course damagingly disempowering for those at local level and flies in the face of good leadership and management practice. The impact of this form of top-down micro-management on the subject of accountability is that all problems and issues, regardless of how minor, tend to flow upwards to the centre once controversy attaches to them. It enables a situation where the Minister, the DG, a national director – regardless of the facts of the situation – invariably end up being the only persons held accountable by the media or by an Oireachtas committee – and this happens almost instantaneously. What this actually means is that those whose “action” or “inaction” actually led to the controversy often get to hide in the shadows and are rarely held accountable. It is this faux, ritualistic form of instantaneous knee jerk accountability that serves to undermine real accountability. It is at the heart of the original design of the HSE.
That is why I am so committed to the creation of local accountable service delivery structures – through the Hospital Groups and Community Health Organisations. It is important to understand that disciplinary processes will always be far from simple – as I described earlier. Unfortunately, we will not see the benefit of having more local responsibility and accountability until such time as we grow up, understand the legal constraints that exist in disciplinary processes and overall; and view accountability in more realistic terms.
A SYSTEM THAT IS TOO EXPENSIVE
For many years now we have merely tinkered around the edges of reforming our health service that has pretty much remained unchanged over the past 50 years. We have enhanced the range and quality of most of the services that we provide and in some specialities we are as good, if not better, than most of our neighbours in the Western world – despite some people’s best attempts [for their own self-serving reasons] to talk down our services. However, year in year out, we are obliged to work with a system that because of its design is too expensive because we have failed to grasp the thorny thistle of fundamental reform. This involves courage, hard choices and looking beyond what we are used to. It also involves each of us peeling back the arguments of the many vested interests in the health environment – that we see so readily carried by much of our media and politicians – as it tends to make good provocative headlines. I would also urge vested interested groups – especially representative bodies to follow the example of NHS Scotland and the BMA who have taken a decision to stop “talking down” the role of GPs as it is impacting significantly on their ability to recruit GPs and instead are pointing to the many positives of that role. If we can move beyond this point we might then move towards a consensus on health that will allow us to finally leave any residue of dysfunctional health care delivery behind us – for once and for all.