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Interview - Staff, safety and social supports

HSE director general, Tony O’Brien, doesn’t believe health service staff numbers can be reduced much further. Interview by Niall Hunter

Why does the HSE have such a negative public image?
It’s negative because from the moment it was established, every act, sign of omission or commission, by every health board or health entity that ever existed before, was immediately labelled as relating to the HSE. Also, the manner of the HSE’s creation was sub-optimal. It happened very quickly and, with the benefit of hindsight, too many things were pushed together too quickly without enough attention or time to be paid to fundamental issues that could have changed the characteristic of the health service.

Such as?
Well, for example, systems. There was no time to prepare appropriate integration of systems so, even now, the HSE has great trouble producing national data on a number of things, even basic financial data.

The merger of health boards happened under circumstances where it wasn’t possible for the organisation to ‘delayer’ itself. It created additional layers of bureaucracy which have taken a long time to reduce, and that became quite paralysing for the organisation. Many people inside it felt disempowered, unable to do their best work, and as a result the high expectations created for the HSE were very quickly dashed.

Notwithstanding staff reductions of recent years, do you think there are still too many managers and not enough frontline staff?
The reality is there have been very significant reductions in administration staff. Clerical or management admin actually includes a lot of things that aren’t really in that category. There is a range of specialist staff within that category, for example the staff who check patients into an outpatient clinic, who would be classified as admin. A whole raft of things, which are really customer-facing, are classified as management and admin, and many clinical staff will tell me they are suffering from a shortage of the appropriate skill mix in this area, which would enable them to do their best work.

While some staff may have left from sectors in which they were badly needed, are there areas that could actually be downsized further?
What I’d want to do is look at those activities that we are currently using staff for that could potentially be provided by other service providers outside the HSE, and then use the staff we do have for things that need to be provided as a core part of the health service. If the absolute freedom existed to do so, I would prefer the clerical and admin staff that we have left to be doing things that directly support patient care, customer interaction, the medical card scheme, health promotion etc.

Some of our accounts payable functions could potentially be contracted out to other service operators. Obviously in saying that, I would caution that there are provisions under the Haddington Road Agreement which would stipulate that very specific processes would have to be gone through, so I wouldn’t want to give the impression that I am about to outsource a whole raft of functions without due regard for policy, but these things can be done in certain ways. As part of the overall reform programme I feel it is something we definitely have to look at.

Do you believe there has been a lack of clarity to date on future health structures in the reform process once the HSE is abolished? Are there going to be far too many ‘quangos’ accompanying universal health insurance?
No, I think in the immediate post-HSE phase, it’s clear there will be seven hospital groups, and a certain number of community health organisations. They will all be commissioned and funded through a Healthcare Commissioning Agency. Then there will be the Department of Health, various regulatory bodies and a new patient safety agency. I think there is a relatively clean diagram of what the entities will be.

There seems to be a plethora of new and existing organisations involved. Are we going back to the pre-HSE, health board system? No, I wouldn’t agree. The hospital groups are nothing like health boards.

With the advent of the clinical programmes, with hospital licensing, with standards for safer healthcare, it is very clear what each hospital group has to do and how it should do it, but in terms of how they organise resources within the group there will be more freedom, but they’re not comparable to health boards.

There’s a view, which I would agree with, that the HSE as a single construct is simply too big to be effective. To move away from one thing that’s too big you have to have several other things that are less big. These changes all revolve around universal health insurance. Do you think UHI is affordable and will it be introduced by 2019?
All of these other changes would be appropriate whether or not we were heading to UHI. We’re now entering a period of consultation on what the basket of care (of services to be covered under UHI) should be. I have never made any secret of the fact that I am a strong personal believer in the principle of universal healthcare, where access is based on need and not economic means.

The only way you can get there is either by an NHS-type model or a universal health insurance type model. Both of them appear to be reasonably valid models. Under either model, the one thing that’s clear is that it’s people of the country who are paying for the healthcare, there are just two different routes of doing it. I’m in no doubt as to the degree of commitment of the government to moving on the road to UHI.

How concerned are you about healthcare safety issues in the context of concerns about the sustainability of year-on-year cutbacks in the health service?
Given the upward trajectory of demand and the downward trajectory of resources, there is going to come a time where the bottom has been reached. Some argue that we may have reached that bottom already. I would be perhaps more concerned about the impact of head count limitations on the health sector, for two reasons. One is that you can’t really have a never-ending downward upper employment ceiling unless you have tested and ensured that the ‘floor’ level is also correct in terms of the basic numbers of staff that you need for each service that you have in the totality of services that are necessary to meet the needs of the population.

The numbers that we have had haven’t been derived from that type of an exercise. When you have an arbitrary number of staff that decreases year on year, and is determined by a process that isn’t fully connected to need, then it is essentially a crude process. The ‘grace period’ exit programme which occurred in early 2012 led to a 5% downsizing of the HSE pretty much on a single day. No manager or policy maker was able to sit down and say this is where we need to reduce staff numbers. It was a case of ‘put your hand up and you go’.

The net effect of that is that a huge amount of institutional memory – experience and skill sets – was lost from the organisation. As a result, many units in the organisation, but for the deployment of temporary staff at great expense, would have ceased to function. As a result of this we have seen an increased reliance on agency personnel which pushes up the cost of labour, introduces instability into the workforce, and all of those things are known to have an adverse impact on the overall quality and cost of the health system. The government has now put back what would have potentially been a further exodus this year, through a further ‘grace period’ early retirement scheme.

I would not argue for compulsory redundancy but I would be in favour of having a degree of discretion on both sides, where people can volunteer to leave but there can be no automatic right to go.

Do you think it is feasible for staff numbers in the health service to be reduced any further?
I don’t believe that staff numbers in the health service can be reduced very much further, if at all. For example, in the maternity area, we are going through an analysis using a tool called Birthrate Plus (to analyse staff ratios) – we will be looking to do similar things to benchmark the appropriate staffing and appropriate skill mix in different services. There will be variable answers; some services are better staffed than others, some are understaffed.

Do you think that at this stage the recruitment embargo can be eased, particularly in areas such as nursing?
It’s not an absolute recruitment freeze. It’s a ceiling above which you cannot go. So we are actually recruiting. In the context of current reforms I would hope that arrangements can be made so that the very large numbers of staff, particularly in the nursing area, who are currently in agency employment but substantially working for us at higher cost, that we could arrive at a situation in which we could convert those into regular longterm temporary staff.

In this way, there would be more stability for them, a better employment situation for them, a lower cost for us, and likely to increase the quality of care provided through the benefits of consistency. We are now excessively dependent on agencies for highly specialised nursing staff and that’s a particular weakness in our system.

In light of recent reviews in the wake of safety incidents, is it feasible to keep some smaller maternity units and EDs open?
I think there is a real underlying issue of sustainability. There is a review of maternity services and a review of ED services in the Dublin region. There are legitimate questions about how we used the resources available in light of all the evidence about how to provide the safest most sustainable care, and whether that will require changes to the configuration of services such as maternity units and EDs.

It will be very much driven from a quality perspective. I don’t see it as a way of reducing overall costs. The number of births we have each year will still have to be provided for. If you are going to have a smaller number of units, that number will have to have greater capacity.

Is it inevitable then that some maternity units and EDs will, if not close completely, have their roles changed and no longer provide the current level of services?
Well, I’m not going to prejudge the outcome of the maternity review. By comparison with some other countries it’s not that we have particularly small maternity services, it’s a question really of whether they are sustainable safely, given the relative unattractiveness of certain locations for staff etc. It’s a whole series of ingredients that need to be examined to ensure we have safe sustainable maternity services. The ED issue is a little more clearcut.

Objectively, for a city the size of Dublin with its current population, the spreading out of ED resources , the fact that we have so many hospitals seeking to be both elec tive and emergency admission hospitals, leads to the probable conclusion that there is a better way of doing things and that work is ongoing.

After so many treatment scandals, do you think the HSE is finally dealing effectively with the maintenance of safety standards and risk management?
Do I think it’s fixed yet? No, there is always more to do. We are acting on the chief medical officer’s report into Portlaoise and we are awaiting the findings of the HIQA review.

While many recent scandals have been shocking, were you particularly shocked at the way patients were treated and followed up in the Portlaoise case?
Yes, shocked would be the only word for it. There are two issues. One is the actual quality of care and the other is the way in which patients were dealt with in the aftermath of adverse incidents.

Every healthcare system in the world will have adverse events, but the way in which grieving parents were dealt with was, frankly, hard to comprehend. I was shocked and concerned about it and that’s why I wrote the letter to all staff in the health service.

I felt that there was an opportunity to engage people in a thought process and drawing a line in saying we simply can’t do that anymore. Something seemed to have become accepted as normal behaviour which, objectively, was simply not acceptable. The message I was conveying was ‘let’s pause for a second and say that must never happen again.’

Do you accept there is a serious shortage of midwifery staff in the system?
Under the HSE’s Director of Nursing and Midwifery, we are going through the Birthrate plus exercise. There are certainly varying patterns of ratios between midwives and births and we need to see how that lays out across the country nationally and then see what we need to do about it.

How does that tie in with the probably accurate public perception that the HSE often fights legal cases taken following adverse events right up to the steps of the court?
The HSE is not in charge of its own representation where legal proceedings have been initiated for damages or compensation. By statute that function is performed by the State Claims Agency. So it’s not the HSE that does or doesn’t settle on the steps, or settle in advance of the steps. Once legal proceedings are initiated, it’s the State Claims Agency that is in charge of that matter. In these cases, we tell people unambiguously that their claim is now to be forwarded to, and will be managed by, the SCA and no longer by the HSE. But clearly, as a society, we do need to find a different and better way to settle and deal with cases where people have suffered loss, or consequential loss, as a result of failings in the health system.

It would clearly be better if there was a way for at least some cases to be dealt with on a non-adversarial basis. I would hope that we can find a way where parents or individuals who have suffered harm wouldn’t have to spend so much of their lives pursuing a case. The leadership of the HSE would be strongly supportive of moves towards, for example, mediation and no-fault compensation. We certainly have no agenda of dragging cases out.

‘The HSE has been downsized by voluntary exit programmes, but this has been entirely unstructured; a fairly blunt instrument. Quite a lot of staff have exited under these voluntary programmes from areas which have been development priorities’. – Tony O’Brien

On the recent controversy over medical card cuts, the public perception is that thousands of people are losing their cards or having them downgraded. Has the HSE failed to explain to the public what it has been doing?

We haven’t failed to explain it, but I don’t think the message has fully got through. In the past three years there have been some changes to eligibility thresholds. That has affected the basic entitlement to a medical card for some people.

The discretionary route to a medical card is founded on the undue financial hardship test – that has always been transacted on the basis of a higher financial threshold than the standard threshold for a card. That’s been applied consistently since the recent centralisation of the medical card service.

As a result of that there have undoubtedly been some instances where medical cards were granted outside of those terms in the past that haven’t been renewed, or have been withdrawn. But there have been no ‘cuts’ to the medical card system per se. The medical card system is costing more and more all the time, so there is no cut to the overall level of expenditure.

Then why are we hearing so much about people losing cards, about people with special needs or medical conditions having cards withdrawn?
Because they either never did, or no longer, meet the financial hardship test set out in the 1970 legislation. I accept that we live in a society that would prefer that we had a medical card system that took medical circumstances into account in a direct way, eg. if you have X or Y medical condition that will or won’t entitle you to a medical card. There is a certain range of medical conditions where there is probably a societal consensus that perhaps that [these conditions] should entitle people to a medical card, but, the problem is, that is not what the law says.

The 1970 Act allows me to operate discretion in terms of granting medical cards, but it has to be done on an even-handed, equitable basis so that people in a similar situation are treated in the same way and, for the moment, this financial formulaic approach serves that purpose.

Isn’t that a bit of a blunderbuss approach?
It probably is. It’s one of the reasons why I’ve put together a small group to examine whether there are different ways of exercising discretion which would be equally robust in terms of satisfying the test of good public administration, and there will be a report on that in the nottoo- distant future to see whether I can give directions to enable discretion to be exercised in a different way.

I’m also concerned that standardised approaches do mean sometimes that people whose individual circumstances haven’t changed at all can, on review, when judged against a clear rule set, see that they are no longer eligible for a medical card. That can be very difficult for them to understand if their individual circumstances haven’t materially changed but, maybe in the past, they were granted a medical card in circumstances where they ought not to have been.

So we need to be able to look at ways we might be able to deal with those situations in a more sensitive way, and we are getting advice in relation to that.

Interview - Staff, safety and social supports


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