Just who is in charge of hospitals in this health crisis?

The health minister wants heads on plates over the emergency department crisis, but the labyrinthine management structures in the health services may make his targets hard to choose. Caroline O’Doherty tries to untangle a very messy bureaucratic web.

"You either decide that health is a priority or you accept this annual crisis. That's for Cabinet to decide"

Health Minister Simon Harris has been engaging in some tough talking by ordering reviews of health managers’ performances and suggesting he might replace them with external experts to try to get to grips with the crisis in emergency departments, but what’s not clear is who he is talking about.

Pinning down who actually manages EDs and is, or should be, responsible for patient flows, resource allocation, long-term planning, and pressing the panic button when numbers become dangerously high, is tricky in a service that operates in a system governed by structures that at times look designed to obfuscate.

The top seems the obvious place to start looking for the person where the buck stops but presuming the minister isn’t thinking of firing himself, attention falls on the layers of management in the HSE.

As director general of the HSE, Tony O’Brien holds the most senior post but that puts him in charge of close to 100,000 staff, a budget of €13bn, and 1.3m ED attendances annually.

That’s in addition to the 1.5m inpatient or day-patient cases, 3.3m outpatient attendances, and millions of other attendances and treatments handled by healthcare providers outside of the hospital network.

While he is answerable to the health minister, it’s unlikely he would be held solely responsible for ED overcrowding. Harris has already deemed it to be so by putting O’Brien in charge of the review of the other health managers.

So where will he start? O’Brien heads up a HSE leadership team that boasts 17 senior managers, 14 of them holding the title of national director of a given area, such as primary care, mental health, and so on, plus two chief officers and a head of programme.

Seven of the national directors, plus O’Brien, make up the HSE directorate which replaced the HSE board. The board had been a mix of Department of Health and HSE staff and was chaired by the secretary general of the department.

Notable in the current context is the omission of Damien McCallion, the national director for emergency management, from the directorate. McCallion is in charge of the winter initiative — the very plan meant to prevent the current chaos.

In the HSE’s own words: “The aim of the winter initiative plan 2016/2017, is to provide a focus on specific measures required to address the anticipated surge in activity experienced this time of year across the hospital and community.

“One of the key objectives is to reduce the numbers of people waiting to be discharged from hospitals and who require specific supports and pathways to do so. In achieving this objective, the capacity of the acute hospital system will be improved and in turn the patient experience in the emergency departments and the wider hospital system will also be improved.”

That hasn’t happened so who takes the heat for its failure? When the directorate was formed in 2013, James Reilly, the then health minister, said: “The new directorate is accountable to me, as Minister for Health, for the performance of the HSE.”

So does that means there is collective responsibility? And if so, is it collective responsibility for the overall performance of the HSE or for each individual area of service within it?

If that’s the case, how much responsibility lies with the national director for acute hospitals, Liam Woods, one of the eight directorate members?

Woods’ brief covers the 48 acute public hospitals across the country and the myriad services they provide, so it’s unlikely he is intimately acquainted with each and every individual ED, of which there are 29.

But he has help in the form of the chief executives of the seven hospital groups into which the hospitals are arranged in clusters of between three — in the case of the Children’s Hospital Group — and 11 as in the Ireland East Hospitals Group.

The hospital groups are responsible not just for services in hospitals, but for linking up with community and primary care services so that patients better managed outside of hospitals do not end up as, in that despised phrase, bed-blockers.

As the HSE code of governance puts it: “Each hospital group is required to develop a strategic plan to describe how [among other things] they will achieve maximum integration and synergy with other groups and all other health services, particularly primary care and community care services.”

Tony O’Brien, the director general, appoints the group CEOs. The groups appoint their own chief operating officers and clinical directors. The groups also have boards and chairpersons, appointed by the Minister for Health.

Just to muddy the waters, there is also a special delivery unit and an ED task force implementation oversight group, both a blend of HSE and departmental personnel.

But back to the HSE structures. Answerable to the hospital groups are the CEOs of the individual hospitals in their group — again, as many as 11 or as few as three. Here’s where it gets really complicated.

When a patient arrives at an ED, either by ambulance or under their own steam, they are a medical case and ultimately the responsibility of the emergency medicine consultant on duty. If there is one on duty.

There are just 78 emergency medicine consultants in the country so there is no way they can cover every ED on a 24/7 basis. Several EDs don’t even have one full-time consultant assigned to them.

In the absence of a consultant being physically present in the ED, there should be one on call but in an emergency, ironically, it may not be possible to get their input into a case so it is left to the non-consultant hospital doctors, also known as junior doctors and generally divided into registrars and senior house officers, to make the decisions around diagnosis, treatment, discharge, or admission.

Once a decision is made that a patient needs admission, a referral is made to the consultant in whatever speciality the patient requires — surgery, cardiology, and so on — and the on-duty hospital bed manager, who may be a full-time bed manager or someone with other responsibilities, is informed. Then the search begins for a bed.

If there is no bed immediately available, the patient remains on a trolley, usually moved to a spot along a wall in a corridor, if indeed they haven’t been there all along. In theory they have been referred to another part of the hospital to another consultant and to the care of ward nurses and doctors but as they can’t physically make that happen, the patient remains under the care of ED nurses and doctors.

These nurses and doctors are still dealing with new arrivals without being able to move on those they’ve already attended to. So the corridors begin to fill, the staff begin to get swamped, and the pressure begins to mount.

If the situation begins to become unmanageable, the ED operational manager — who may be a 9-5 administrator if such a post exists or more likely is the on-duty clinical nurse manager — will liaise with the bed manager in informing the hospital’s senior management team; generally the hospital CEO, the director of nursing, and clinical director.

Health Minister Simon Harris is challenged by Vera Twomey and her husband Paul Barry during his visit to Mallow General Hospital to open the Mallow Injury Unit. Picture: Denis Minihane

These three between them will decide if they should make a request for the ED to go off-call. That request will be made to the hospital group CEO for the final decision, bearing in mind the impact on the other hospitals in the group.

In reality this rarely happens, and it is virtually unknown outside of Dublin because the regional hospitals are too far apart to safely reroute emergency cases.

A less dramatic alternative is escalation policy. An ED escalation plan is meant to kick in once patient numbers and waiting times reach certain trigger points but generally, if 40% of the treatment bays are occupied by patients deemed in need of admission, it’s time to declare escalation necessary.

What should happen then is that extra staff are called in, if any are available; consultants throughout the wards start doing second rounds of their patients to see if any have improved enough since earlier in the day so that they can be discharged rather than waiting for the next day’s scheduled rounds, and elective surgeries should be cancelled.

As a further step, extra trolleys can be put on wards but that’s a decision for the hospital’s senior management team, unlike the escalation plan which can be put in place by the ED operational manager.

According to Liam Doran, general secretary of the Irish Nurses and Midwives Organisation, escalation doesn’t happen often enough and it’s partly because of the ambiguous management structures.An ED operational manager’s seniority and influence may not be sufficient to motivate all those involved in making escalation work. Even though it’s meant to be ED conditions rather than a single person who dictates when escalation kicks in, Doran says that’s not always how it is viewed.

“We would question that when the operational manager, usually a nurse manager, makes the call for the escalation plan to be activated, who listens? And if it doesn’t happen, or doesn’t happen adequately, how is that retrospectively assessed so that it happens in future?”

He’s pointing a finger at consultants here, claiming that being called in while off duty and seeing their elective surgery list cancelled “goes down like the proverbial lead balloon”.

But, he adds, it’s not all down to them. “We need more consultants. They are the ones who can make things move in an ED. They will make the faster clinical decisions, decide what tests are necessary, interpret those tests, and make fast calls about who needs admission and discharge. They have the experience and expertise to do that.

“When you run EDs with junior doctors, they will practice defensively, wait for all sorts of tests, keep patients longer — all perfectly understandable but not helpful in an overcrowding situation.”

Simon Harris cuts the ribbon with, from left, MEP Deirdre Clune; Kathryn Reid, injury unit; David Stanton TD; Dr Gerard McCarthy, Mallow/ CUH; Seamus McGrath, Cork County mayor; Claire Crowley, hospital manager; Kevin O’Keeffe TD; and Brenda Herlihy, director of nursing.

Escalation is only a short-term response, however, and ultimately Doran says there is a dire need for new wards and more beds. On that point he has the total agreement of Dr Fergal Hickey, an emergency medicine consultant and spokesman for the Irish Association of Emergency Medicine.

“EDs work well when allowed to do their job, when they’re not taken up by people who need to be admitted to beds. But we have 2.8 acute hospital beds per 1,000 of the population when the OECD average is 4.3. We need more beds.”

That’s not exactly a new conclusion, which begs the question, who isn’t taking it on board; or, when it is taken on board, who isn’t flexing their muscle sufficiently to see that it’s acted upon?

“It always gets passed up the line,” says Dr Hickey. “We make representations on a frequent basis to our hospital management and other consultants do the same in their hospitals.

“Management usually accept the argument and pass it up the food chain to the special delivery unit and to the hospital groups.”

And then? “It goes higher. I am no friend of the HSE bureaucracy but I wouldn’t accuse the HSE bureaucracy of not knowing what’s going on.”

So would he accuse them of failing to act on what they know?

“Ultimately the person who writes the cheques is not in the HSE or even the Department of Health. It’s the Minister for Public Expenditure and Reform.

“The Department of Public Expenditure and Reform see health as they’ve always seen health — as a basket case which could spend every cent the country ever could earn. But you either decide that health is a priority or you accept this annual crisis. That’s for Cabinet to decide.”

Who’s Who In The ED Saga

Government: The minister with overall responsibility is Simon Harris, Minister for Health but arguably Paschal Donohoe, Minister for Public Expenditure and Reform, has at least as much influence as he holds the public purse.

Health Service Executive: Tony O’Brien, left, director general of the HSE, is the most senior person and he, with seven other senior managers, form the HSE directorate.

The others are: Liam Woods, national director for Acute Hospitals; Philip Crowley, quality improvement; John Hennessy, primary care; Pat Healy, social care; Stephanie O’Keeffe, health and wellbeing; Anne O’Connor, mental health and Stephen Mulvany, chief financial officer.

With Damien McCallion, national director for emergency management, seven other national directors, a chief officer and head of programme, they collectively make up the HSE leadership team.

Hospitals: Hospitals are organised in seven groups, each with a chief executive, chief operating officer and clinical director.

The chief executives are: Mary Day, Ireland East Hospitals Group (Dublin, Mullingar, Kilkenny, Wexford); Ian Carter, RCSI (Dublin, Drogheda, Dundalk, Cavan, Monaghan); Susan O’Reilly, Dublin/Midlands (Dublin, Naas, Portlaoise, Tullamore); Colette Cowan, University of Limerick (Limerick, Ennis, Nenagh, Croom); Gerry O’Dwyer, South/South West (Cork, Waterford, Kerry, South Tipperary); Maurice Power, Saolta (Galway, Sligo, Letterkenny, Mayo, Roscommon); Eilish Hardiman, Children’s Hospital Group (Temple Street, Our Lady’s, Tallaght).

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