Let the HSE run hospitals only and leave everything else to the locals

BANKS tend to be big employers. For instance, most of the largest private sector employers in Europe are banks — HSBC Holdings, BNP Paribas, Royal Bank of Scotland, Credit Suisse.

There are big manufacturers, too — the petrol refiners ENI in Italy, electronics manufacturers Siemens, the enormous French retailer Carrefour.

You could go on with lists like this for hours. All these companies, and many more, are household names, and all count their annual revenue in tens of billions. Not one of them employs more people than the HSE does.

The HSE is not just our largest employer, it would rank up there with the largest employers in Europe. Well over 100,000 people, directly and indirectly, are employed by the HSE. Its budget is in excess of €12 billion. There isn’t a single town in Ireland where the HSE’s presence isn’t felt.

But the HSE can only be compared to the giant companies I’ve mentioned in some respects. It is not supposed to make a profit — if it does, it is heavily criticised for hoarding money while needs aren’t being met. But neither is it supposed to make a loss. If that happens, the heavens can open and it can be instructed to make savings at whatever cost.

The HSE is supposed to anticipate the future, but isn’t allowed to plan for it. If the needs of its ‘customers’ aren’t capable of being met within the budget allocated to it, it’s the budget rather than the customers that must take priority.

And the HSE must account also to ‘shareholders’ whose only interest is in seeing the books balanced — and in avoiding blame themselves for anything that goes wrong.

Unlike other companies of its size, the HSE never makes policy, it only implements other people’s policies. And if those policies and priorities change with every wind that blows, that’s too bad.

All of the big companies I mentioned at the start are taken from the Forbes listing of major corporations. Apart from size and scale, those companies have many other things in common, too. They invest in innovation. They take their customers seriously. They emphasise quality. They implement change when it’s needed, often ruthlessly.

They research. Of course they’re motivated by profit — and when promise isn’t matched by results, heads roll. When the business is going through tougher times, they cut — but never, if it can be avoided, at the expense of being able to provide the service their customers are willing to pay for. The HSE isn’t able to do any of those things. It was set up to absorb not just all hospital care, but all community, social and personal care into one huge national organisation.

It doesn’t just look after people who are sick or threatened with illness. It also has statutory responsibility for the needs of elderly people, for the challenges faced by people with disabilities, for the protection of vulnerable young people, for the care and treatment of people dealing with mental health challenges.

The HSE was set up as a national organisation because it was believed that a single national organisation would have the flexibility to move resources around, to respond to changing needs quickly, to stretch resources further. But it hasn’t been allowed to become a single national organisation.

In fact, right now, it’s 32 different organisations. Each of the 32 local health offices has remained virtually as powerfully autonomous as in the days of the health boards. If resources need to be stretched or if cutbacks need to be made, they can only be made within each area, rather than across the areas.

So, because the HSE has been told to cut back its spending, all sorts of blunt instruments have to be employed.

If there’s a shortage of staff to meet, say, a long waiting list for dental treatment in south Dublin, then a queue has to form in south Dublin. It doesn’t matter that there could be a bit more staff than is needed down the road in Kildare, say. The single national organisation can’t cope with that.

But the biggest issue is the shareholder one. The HSE was designed and set up by politics, and it was a peculiar form of politics. Yes, there was some interest in setting up a body that could do a better job in channelling resources, but there was also a lot of interest in having something to hide behind.

The HSE was, in effect, cast adrift the moment it was set up and has been starved of political guidance and vision ever since. And worse than that, it has been starved of political accountability.

The HSE is run by committed and highly competent people. In my day job, I meet HSE managers regularly who are totally absorbed, in some cases around the clock, in trying to provide services that are of high quality and accessible when they are needed.

I’ve had encounters all around the country with HSE staff at all levels who are passionately engaged in trying to deliver on the ground. They’re nearly all at their wits’ end. Right now, even though it’s only a couple of years old, the HSE is in the middle of its biggest crisis. Up to now it had to deal with a wide range of individual and local crises, and for good or ill the truth is it inherited most of them. But there is a real crisis of confidence now in the HSE, and it’s affecting the entire organisation.

They know it isn’t working. They know the task of building a single national organisation that can plan for the future and invest in its own research and innovation is never going to be completed.

THERE are too many fires to be put out, too many shifting political priorities, too much focus on one aspect of the organisation’s work (A&E, for instance) and none at all on many others.

Because every crisis leads to a change in policy and different priorities, the pressure on resources will never end.

Despite the fact that the organisation is still young, there are visible signs of burn-out in many of the overburdened people you meet.

Is it time to think again? It may be possible to build a single national organisation to run our hospitals and to ensure that across the country the spread of excellence is real. We are going to need to debate whether the time has come for the HSE to be dedicated to that job, and that job alone. That would mean the HSE stepping away from responsibility for the enormous range of other issues it has to deal with.

And that in turn means finding new ways to deliver services to elderly people, people with disabilities, vulnerable children and all the other groups who depend on effective delivery.

Unlike the argument about centres of excellence, though, the wide range of social and personal services currently handled by the HSE would be best delivered through locally accountable and managed structures.

It might sound like back to the future, but the more we decentralise the delivery of care in the community, the stronger it will be.