A clinical approach to health reform

CATHAL Magee is a man with rather a lot on his mind.

As HSE boss, he is grappling with a near impossible challenge: How to reform a creaking health service at a time of unprecedented cutbacks in funding.

He must deal with Health Minister James Reilly who is planning another major structural overhaul.

The HSE behemoth is to be broken into a series of functional directorates as part of an effort to boost visibility when it comes to monitoring expenditure, running at over €13 billion a year.

But behind all this is a concern that the Department of Health is reaching out in order to exert greater control, leaving Mr Magee in an uncertain position, at the risk of being stripped of much of his authority just when he is beginning to get to grips with what is an extremely wide-ranging brief.

The imminent departure of HR director, Sean McGrath could have been better timed given the pressures on his boss.

The HSE’s National Service Plan for 2012 makes for rather grim reading. Some €750 million in cuts will be delivered on top of cuts of €1.5 billion achieved over the past two years.

In recent months, closures of public nursing homes have been announced around the country. The removal of services at Roscommon hospital led to local Fine Gael TD Denis Naughton resigning the party whip.

Protests are building. Unions such as the INMO representing nurses and midwifes are as vocal as ever. Reforms to rostering arrangements sought as part of the changes agreed under the Croke Park Agreement are proving elusive.

Mr Magee’s approach has been to go quietly about his business, resisting the temptation to court controversy by means of public pronouncements.

He is much more media savvy than his predecessor, Professor Brendan Drumm.

Mr Magee prefers to deliver carefully thought out presentations at conferences resisting the temptation to respond to the utterances of local politicians, union officials and various representative organisations.

As a result, he has won some respect.

Mr Magee started out as a clerical officer with the North Western health board in 1977, eventually rising to the position of industrial relations manager with the Western Health Board.

Between 1988 and 1992, he worked in Bord na Móna at a time when the company was being overhauled under the chairmanship of Brendan Halligan. Bord na Móna underwent a remarkable transformation, particularly under Eddie O’Connor as chief executive in the early to mid-1990s.

By then, Mr Magee had moved over to Telecom Eireann serving as HR director, managing director of business transformation and eventually managing director, Eircom Ireland. He was an enduring presence in a company in constant flux, with privatisation and an IPO, the move into ownership by a consortium of private investors, reflotation and reprivatsation.

His reputation stood up against this gale of events, planned and unplanned. In 2009, he served as acting chief executive for six months before being passed over for the top job in favour of Paul Donovan.

As it turns out, an even bigger challenge was lying in wait, a call from the then health minister, Mary Harney for him to step into the HSE breach. Mr Magee has built on Prof Drumm’s undoubted achievements, proceeding with the roll-out of the National Cancer strategy. He is also pressing ahead with the roll-out of new primary care clinics and an extra €35m has been found for mental health.

Mr Magee has offered some insights into his management philosophy. He has emphasised the importance of planning in leadership and the importance of “crafting” a vision.

In his view, decisions begin with a diagnosis of the existing problems, “a painful process”, in his view. “People prefer to articulate how it is supposed to be rather than how it is.”

The HSE presents a unique challenge in combining huge ongoing budgetary pressures, the political cockpit of local health politics and the presence of powerful unions and professional groups, each of which are willing to defend their interests without compunction.

Mr Magee has stressed the need to introduce up-to-date management techniques. At the Health Management Institute of Ireland conference recently he talked of the need to separate management from administration, insisting that a significant investment in management as a strategic priority is required — a nice way of saying that he does not hold a particularly high view of management practices within the HSE.

He is keen to bring clinicians into management roles — ironic given that he himself succeeded a clinician as chief executive.

He concedes it will be a big challenge to encourage clinicians to stay with the implementation agenda, given problems with resources. All of which gets back to the Croke Park deal which effectively preserves very high medical pay rates at a cost of high job losses and a squeeze on resources.

Few believe the unions have yet really delivered in areas such as rostering, the med laboratory service being the much touted exception.

It all boils down to hard cash. In 2001, the health service cost €7bn to run. In 2009, this jumped to €15.5bn, in 2011 it was down to €14.5bn and another €750m must be rung out. Employee numbers are coming down. Salaries and pensions here are running at around twice those in the British NHS across many areas of doctoring.

It seems crazy to sustain high salaries and pensions at the top while operating an embargo on recruitment which is getting in the way of plans to boost service delivery while encouraging the leakage abroad of expensively trained talent.

That, however, is a political decision — taken to avoid industrial relations turmoil — taken by people other than Mr Magee.

Eighteen months into the job, and with James Reilly driving his own strong reform agenda, Mr Magee must know that he is perched on a near vertical cliff face, aware that the merest stumble can turn into a terrible tumble, one that could impact upon us all...