Don’t blame the HSE — rather, look to the ‘monster’ that created it

IT appears from all the newspaper reports that the HSE is facing a financial crisis. And it seems as if the organisation, set up to meet the needs of our entire population for healthcare and a great deal more, is going to have to face that crisis alone.

The only way out, according to the media reports, is an immediate ban on recruitment of frontline staff.

That will have serious consequences, and indeed they could be devastating. But the newspapers don’t seem to be too interested in the consequences. So far, all I’ve read has been coverage of the fact that the HSE’s financial deficit is growing, coupled with endless criticism of management for allowing this to happen.

Especially in financial terms, the criticism seems to me to be crazy. At the end of last year, the HSE recorded a deficit of €78 million on total expenditure of close to €12 billion that’s a deficit of about two-thirds of 1%.

If any private sector company, operating in an environment where some of their key costs are outside their control, brought in a deficit of about that size, the financial analysts and the business media would be showering them with praise.

Last year was the second full year of the HSE’s operation — in its first year it recorded a surplus of about the same dimensions.

And guess what? It was roundly criticised for the surplus, too.

It’s part of the dilemma the HSE faces. If it makes a loss in any particular year, it is attacked for financial incompetence. If it records a surplus, it is attacked for hoarding money while critical needs aren’t being met.

Well, I work for an organisation that has to meet all the same criteria that the HSE faces, though on a much smaller scale. We have to seek to operate to the highest standards of quality and accountability we can, to balance our income and expenditure, to operate as a good employer, to meet the needs of our communities and families, to keep our profile reasonably high, and to raise the funds to do it.

I often think the job of trying to pull all that together is a pretty complex and demanding one.

But when I look at the HSE, with its total staff more than 300 times bigger than ours, its annual budget nearly 500 times bigger than ours, and with a commitment of one sort or another to every city, town and village in Ireland, I often find myself wondering how it is possible to make any headway at all. In fact, I reckon we’re pretty lucky that HSE management is as dedicated and committed as it is. That’s not to say there isn’t a problem, or indeed that the HSE doesn’t warrant criticism from time to time.

But the real problem is much deeper. The real problem is the lack of any sort of political commitment to the provision of healthcare as a right.

On the face of it, the HSE was set up as an instrument of public policy to deliver the best care possible in all circumstances. That’s what it thinks it’s there for, and that’s what it’s aiming to do.

But, in fact, the HSE was set up as an abdication of public policy and as a way of avoiding political accountability for healthcare. It was given a budget, given a management structure, and told to get on with it. To sink or swim on its own. You’ll probably have noticed from the newspaper reports about the latest financial difficulties that it is the Department of Finance that seems to be exercising control, and not the Department of Health.

According to one newspaper account last Saturday, the Department of Health has simply “told” other ministers that “unless remedial action was put in place, the HSE would face an overall budget deficit of €400m by the end of the year”.

But the same report goes on to say that “the Department of Finance has expressed strong concern at the HSE’s deteriorating financial position and has advised Minister for Finance Brian Cowen on the issue”. Health Minister Mary Harney wasn’t even mentioned in the newspaper reports I read, except to say that she had been assured that frontline services wouldn’t be affected.

It is essentially the lack of political

accountability and the decoupling of the health service from public policy that is the reason why HSE senior management has spent more of its time dealing with crises than implementing strategies, more time fire-fighting than managing.

If it had adequate political support and direction, it would be able to devote its management skills to the building of a real service, and not the stop-start service we have now.

The problem that the HSE faces when it’s fire-fighting is that when a fire is raging, it might have started only in one part of the house. But if it isn’t dealt with quickly, it can burn the entire house down.

Take the current situation. The deficit has been caused by some overspending in the hospital sector and on statutory, demand-led schemes such as the drug payment plan, which subsidises the cost of medicine for patients. Very little of this overexpenditure could be controlled. But in order to compensate, every other section of the HSE has now been told there must be a complete shutdown on recruitment. Even people who have been offered jobs, and haven’t yet started, will have to be told their start dates have been postponed.

THE HSE, in a letter to every senior manager, has said that “these arrangements apply in the case of all categories of staff and all contractual types… no promotions, acting-up arrangements, recruitment of permanent, temporary or replacement staff, locum or relief staff is authorised…

Resumption of staff following career breaks should also be temporarily deferred…” Now that might (or might not) solve the financial problem. But the staff described in that letter are people who provide essential services to the elderly, to people with disabilities, to vulnerable children.

They are the social workers who won’t be there when a family has a crisis, the physios who won’t be able to help patients recover from a stroke, the public health nurses who won’t be able to keep a close eye on elderly people in the community.

If we think it’s possible to implement a measure as draconian as the one outlined in the HSE’s letter without people suffering, we’re kidding ourselves.

The kind of cuts now being imposed will spread far wider than the hospitals and drugs programmes where the overspending occurred, and will bite deeply into a wide range of community and social provision. Not only will frontline services be damaged, it is precisely at the frontline where the most damage will be done.

But it’s time to stop treating the HSE as the whipping boy for all of this. The dominance of a particular ideology in our politics over the past few years has led to a complete abandonment of political responsibility for our national health service. That’s where the blame lies.