Irish health service’s problem is management, not money

The weather wasn’t the only unseasonable spike this week. Overcrowding in hospital emergency departments are at levels usually only seen in winter. Hotter summers haven’t led to calmer hospitals. The scale of escalation is indicated by the Irish Nurses and Midwives Organisation’s trolley count for June. It says it is 35 per cent above 2019 levels, the last full year pre-Covid. But good news beckons. There are solutions to many of the challenges facing the health service, and we know what they are.

The stubbornness of bad habits is illustrated vividly at University Hospital Limerick. That emergency department is the canary in the coal mine. Two years ago a pre-Covid report commissioned from a team led by Prof Frank Keane for the HSE spoke truth to power. Across nine hospitals the target that 75 per cent of patients achieve an average patient experience time of six hours and 99 per cent of nine hours was missed by all. In Limerick, Keane found a litany of management issues exacerbating underlying problems about capacity. In June this year the Health Information and Quality Authority (Hiqa) reported on an unannounced visit in damning terms. University Hospital Limerick was found to be non-compliant with a host of required standards.

Lessons had not been learned and local leadership is part of the problem. National leadership did not see it that way. It had not published the Keane report because it viewed it as outdated. The HSE is right that a big underlying issue is mismatch between capacity and demand for unscheduled care.

[ ‘He had no privacy, no dignity’: Life and death at University Hospital Limerick ]

[ June worst on record for hospital overcrowding with almost 10,000 patients on trolleys ]

Pouring the new wine of more public money into the old wineskin of a badly managed system will not work.

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There is clearly a bed shortage and that is one capacity to be increased. We are already spending €6 billion more than in 2018. There are almost 15,000 more staff employed than in 2020, including 4,000 nurses and 1,300 doctors and dentists. Excluding additional ICU beds, 854 additional permanent hospital beds are in place since 2020. But all the while waiting lists and waiting times lengthen.

Depending on how complicated you like your plans, there may be up to a half a dozen key steps required. One is more hospital beds. Another is a new consultants’ contract to attract candidates for more than 800 consultant posts that are unfilled on a permanent basis. Strengthening local management is key. There is a lack of basic operational grip at some hospitals. That doesn’t reflect well on management at any level. It is a critical issue as Regional Health Authorities (RHAs) are set up as part of Sláintecare. For those to work, management has to be levelled up locally. At national level, senior management must let go, to allow it to work.

No accident

This brings the Department of Public Expenditure and Reform into focus. Compared with the scale of their responsibility, hospital managers in the public sector are not well paid. Talented people migrate to the private sector. Consultants notionally under their command are much better paid. It is no accident that doctors don’t see management as a career path. In a system hidebound by outdated work practices. Being in management locally implies power that is partly myth. RHAs, and by extension Sláintecare, will only work if the right people are attracted to lead them.

Salary levels are ultimately a matter for Public Expenditure. So are the national pay agreement and public procurement policy. A new consultants’ contract may deliver on them doing public work only in public hospitals. In parallel, there is no serious attempt to guarantee that pay increases ensure flexibilities among health workers generally. On health alone, an additional 5 per cent in public pay due for 2023 will cost €470 million, before another employee is hired. But if a deal is done along those lines, what we get in return in terms of reorganisation is the status quo. That is not management; it is outrageous.

The scale of change that is possible is demonstrated by the fact that up to 70 per cent of patients in emergency departments could be treated elsewhere. A post-Covid surge for postponed care is an issue. Another is GPs and community care poorly equipped for the complex needs of an ageing population. Nearly 20 years since Mary Harney proposed the co-location of private hospitals with public ones, we are messing with a variation of the idea. Three proposed elective-only hospitals to do less complicated procedures are years away in a system where public procurement is more complex than brain surgery. But that’s the Department of Public Expenditure for you. In the meantime minor injury clinics are underutilised and all avenues lead to the emergency department.

The certainty of failure perennially looms over health. It is astonishing how a disjointed system could be cracked into shape for the limited purpose of dealing with the pandemic, only to seemingly lose its mission immediately as the emergency recedes. The contrast with housing is stark. That is translating into a tsunami of permanent political change. But dismal news on health is met with a shrug.

What to do has been clear for years. The missing piece is relentless determination to enforce action within, in a system that must reconfigure to align with a changing population profile. Instead of being mesmerised by complexity — and little of this is simple — what is critically missing is gumption.