HSE needs to focus on managing its various individual strands

I MET a Health Service Executive (HSE) manager at a conference the other day. It wouldn’t be in his interests for me to tell you who he was or where he came from, but he was frustrated. Very frustrated, in fact.

It happens a lot to senior people in the HSE that when people hear where they work, the conversation always takes a particular turn. Everyone, it seems, has an idea about what the HSE should be doing with its money. And there are particular times when those ideas tend to be expressed enthusiastically, even aggressively.

For instance, the HSE is always in a no-win situation, whether it shows either a deficit or a surplus. A deficit means it can’t manage the money the taxpayers give them. A surplus means it is being mean about the services it should be providing. No other organisation in the country is expected to stick so rigidly to the budgetary parameters decided at the start of the year, and at the same time able to plan for all our futures.

And apart from the spending issue, every time there’s a crisis of any kind affecting patients, or children at risk, or people with disabilities, or elderly people, HSE managers get it in the neck from everyone they meet. The crisis might be happening in an area that has nothing to do with them, but that won’t stop everyone giving them an earful of helpful advice — and sometimes abuse.

But none of that had caused this manager’s frustration. He had, in fact, been listening to a long, and very skilful, interview given by Brendan Drumm on that day’s edition of Morning Ireland.

“Patients,” he said. “That’s all the senior people in the HSE ever talk about, is patients. But I don’t have any responsibility for patients. In fact, the people I’m supposed to look after aren’t sick at all. How are they ever going to get a look-in with this mindset?”

Sounds like an odd thing to say, doesn’t it? The HSE was set up to look after people who are sick, right? That’s what it does, right? Well, no. And that might just be the source of the problem. There is a mindset about the HSE that it’s all about illness and health. There may be — there probably is — a mindset within the HSE that it’s all about illness, health, hospitals and doctors. And that may be why there is such a continuing debate, to the point of national preoccupation, about where the real priorities should be.

Look at the figures for just a minute — yes, I know you’re sick of hearing that the HSE has more than enough money to do its job. According to the official Book of Estimates, here’s what the Government has allocated to the HSE for different aspects of its work.

The total allocated to the HSE this year is, precisely, €14,337,600,000. That’s fourteen and a third billion euro. It’s an incredible amount of money. In fact, it’s €3,382 for every man, woman and child in the country. It’s hard to imagine that we couldn’t deliver a virtually flawless health service for that kind of money.

But, you know something? I’ve written just over 500 columns for the Irish Examiner. The second column I wrote for the paper, way back when, was written when Brian Cowen was Health Minister, and it was written in a week when he was announcing that 5,000 women had to face the anxiety of waiting to find out if cervical smear tests were valid. Some things, it seems, never change.

There was no HSE then. The HSE was set up to bring order into chaos, to provide a unified management structure across a wide range of disciplines.

And it was set up to provide effective services for thousands of people who aren’t patients at all. In fact, out of the €14bn, only €5bn is spent on hospital services. And not all those hospital services are for people who are acutely ill. The three maternity hospitals in Dublin, for instance, whose primary preoccupation is not with ill health at all, incur expenditure of around €150 million between them (money well spent, I’ve no doubt, but not, in the main, spent on sickness).

Primary, community and continuing care is what the HSE spends the bulk of its money on — just under €9bn, or almost two-thirds. Of course, some of that money is spent on people who are sick, although not in hospital. But it includes things like (and all these figures come from the Book of Estimates) €191m for home help services for elderly people, €180m for residential services for children, €99m for foster care services for children at risk, €956m on services for people with intellectual disability and autism, €303m on counselling services in the mental health area, €227m for dental and orthodontic services and €207m for pharmacy fees for the medical card scheme.

There are dozens of headings, and all feature spending in the tens and hundreds of millions.

As you can see, that spending might be about preventing illness, or coping with illness in the community. Or it could be about providing services to people who aren’t ill at all, but elderly, or living with a disability.

But if you take any one of the items above at random, or the others I haven’t listed, and ask yourself some questions, the problem of accountability and a better management focus might become clearer.

TAKE just one example from the list. Let’s say (because it really surprised me), the €180m for residential services for children. Who are they, these children? Where are they? Why are they in residential services? Where are these services? What are the services provided? Are they detention, prevention, rehabilitation, medical, psychiatric, counselling services? Who manages them? Who sets standards and ensures they are met? Who guarantees value for money? What are the outcomes for the children involved?

You could apply the same or similar questions to any of the headings. Perhaps the most important one (and the one that is frequently hardest to answer) is the one about outcomes.

But I’ll bet there is no single person in the HSE who can answer all those questions. We all expect Brendan Drumm to know everything there is to know about residential services for children, and home helps for elderly people, and all the rest. But I’ll bet you equally that he would be just as surprised as I am to discover how much the HSE is spending in this area, and how little is known about how it’s managed.

And that is the fundamental problem. If you look at the above list of activities (and bear in mind it’s only a partial list) what you see is this: the HSE is involved in dozens of highly essential things, all of them costing tens and hundreds of millions of euro. In any other enterprise, an individual investment of €180m would require focus, accountability, specific results. Until those disciplines apply to our health service, the pressure will continue.