Time is one of the most commonly misunderstood and miscalculated instruments of power.
Another is the complexity and inertia of public administration. The only profit-sharing schemes for most public servants are tenure and security.
Security, not just as tenure,but the dividend of comfort from challenge, becomes effectively the prioritisation of the private interests of public servants, over the public interest itself.
Usually, it’s not a conspiracy. The public service is overwhelmingly populated by decent people. I had inspiring teachers. I have seen nurses and doctors at their best. The gel that holds systemstogether is inertia. The means is the muscle of representative organisations.
The imbalance of power, between public servants who are time-rich, and politicians who are time-poor, means little changes.
Reform runs out of road, because the occasional politician who supports it, runs out of time. That fuels a downward spiral of cussedness and cynicism.
That reflective raiméis is apt today as the government is set on its next big move in health.
We are to have six regional health authorities. It is the re-organisation of the re-organisation of the HSE which was founded out of multiple health boards in 2004.
Low morale across the health services notwithstanding, it is a bleak study to see how time has been used, misused and abused over the intervening 15 years.
It gives the lie to the sage adviceto “give it time”. Patience in personal relations may be a virtue.
In organisational change, and in challenging vested interests, it is the scarcest resource.
In 2004 a political decision was taken to move ahead with establishment of the HSE, because negotiations to resolve organisational issues would otherwise be endless.
The context then was social partnership. The overriding order was not to rock the boat. The panoply of all the health boards, and all their managers, were kept intact.
The logic of the establishment of the HSE was never followed through on. Worse, a further overarching layer of management was installed to attempt to compensate for the dysfunction of what lay below, but could not be discommoded.
Obviously the finger of blame can be pointed at the unions. And they are central to what is wrong with our health service. But unions are democratic, membership organisations.
They do the bidding of their members.
When a hardworking, caring clinician says they are fighting for patients, ask what are the fights their union has taken up over the years?
What work practices are being protected or what interminable negotiations are being used as effective, debilitating tools to protect a dysfunctional status quo, and frustrate effective change?
Of the more than 100,000 who work in the health service, most have little power. Combined together they are an immovable force.
Aligned in their different areas, there is a series of competing interests, with cross-cutting vetoes.
There isn’t actually enough cynicism to comprehend it. Patients serve as raw material for a flawed production processes that generates longer waiting lists, greater cost overruns, and consequent pressure on government to deliver more resources, into the same failing system.
Much is made by politicians in government of the impressive deliveries of the health services, and a list of significantly better outcomes across a range of illnesses. There is also the fact that we are all living longer.
These claims are largely true. There is impressive and improved delivery in part. One reason this is not as appreciated as it should, is that the modus operandi of those working in the health service, and delivering those better outcomes is to continually decry and do-down what they deliver.
Without a continuing sense of crisis, their power to extract more resources into the unchanging, dysfunction they populate would wither.
I think there was a brief moment of hope things were slowly coming in the right direction, as distinct from going in the wrong direction when Cathal Magee was CEO from 2010–2012. The degree to which things were coming together organisationally then is a matter of debate.
He inherited six years of frustrating, uphill work. But the following through of what was originally intended, was disastrously kicked aside by the incoming minister Dr James Reilly. It was the moment of maximum damage, coinciding with an economic crisis.
The HSE board was abolished, though it survived. Universal health care remains pie in the sky. And critically the opportunity of the economic crisis to impose real organisational change, further down the management food chain and in hospitals was wasted.
Do the maths: 2011 and the arrival of James Reilly was seven years after the establishment of the HSE; Simon Harris’s redrawing of the architecture today is another eight years later. It is a very long time.
What is ignored repeatedly is the complexity, inertia and power of what is being changed. Politicians routinely underestimate the challenge they face. They too often assume that because they are in charge that they are in control.
Minsters control very little and the one thing they must control most, which is time, they let loose too freely and end up running out of. So it may prove for this government. It must rue the passage of time, on health.
Last year’s big additional spend on health was to be the bung, to end all overspends. It wasn’t. Deficits continue to accrue. As IBEC’s chief economist Gerard Brady has pointed out, we have spent €11.5bn in supplementary estimates on health, in four years.
That is €11.5bn above what was planned and which we were told would be adequate. It is €11.5bn extra that is now reinforced concrete in the foundations of health spending permanently, for every future year in perpetuity.
It is the protection money we the citizens have paid to the system, its inmates and guardians to ensure at least the hope of care if required. Our politicians, who largely do as we tell them, have decided they have no mandate to face down the vested interests crippling the system.
THAT cumulative, permanent, recurring €11.5bn puts the once-off €1bn overrun at the National Children’s Hospital in perspective. Despite its scale, it’s chicken feed.
There is an out of control, avaricious monster feeding on ever larger quantities of scarce resources in our health system. What the minister proposes today may be a good idea. But he knows that the responsibility of implementation won’t be his. The enemy is always the same.
It is the deviousness of inertia. Politicians quickly run out of time. Many of them just play for time. Some simply waste it.
Plans for change are good. What is lacking is the stamina to see them through.