Who will appoint the next CEO of the HSE? To whom will that person report? What will be different?
There’s been much clamouring for the head of the CEO, Tony O’Brien, such that he has let it be known that he’s going a month earlier than scheduled, effectively on gardening leave.
I understand the anger. For too many people, the cervical smear scandal is just the last straw.
Tony O’Brien is accountable for everything that happens on his watch. That’s what his large salary is for.
But here’s the thing. As head of the largest organisation ever created in Ireland’s history, there isn’t any way for him to know what is going on throughout the organisation.
And, to be fair to him, he has done more than most to try to change the culture of the HSE.
In 2014, after yet another scandal — this time when babies died in Portlaoise Hospital — he wrote a letter to every person who worked in the HSE. In an interview he gave at that time, he described himself as shocked by what had happened.
“Yes, shocked would be the only word for it,” he said. “There are two issues. One is the actual quality of care and the other is the way in which patients were dealt with in the aftermath of adverse incidents. The way in which grieving parents were dealt with was, frankly, hard to comprehend.
"I was shocked and concerned about it … Something seemed to have become accepted as normal behaviour, which, objectively, was simply not acceptable. The message I was conveying was ‘let’s pause for a second and say that must never happen again’.”
I remember thinking that his letter — in which he said that HSE staff were treating people who could have been their sisters as if they were strangers — was heartfelt.
But that was four years ago, and we know that nothing has changed. Tony O’Brien failed to change the culture of the HSE, not, I believe, for want of trying, but because it isn’t possible.
Since he wrote that letter, there have been many more scandals. People have been mistreated in all sorts of ways. Several major inquiries are going on, as a result.
But as Tracey Cooper, the head of Hiqa, said when she moved on from that organisation that in the HSE there never are consequences. No manager, no professional, no staff member has ever been asked to leave, and none has ever been sacked.
If Tony O’Brien is forced out, he will be the first ever. And, in years to come, he will know that he failed to do the impossible. He failed to change an unchangeable culture.
To come back to the questions I asked at the start. The next CEO of the HSE will be appointed, as things stand, by the Department of Health. Not by the independent board of the HSE, because there isn’t one.
The next CEO of the HSE will report to himself or herself. Nothing, as a result, will change.
This is insane, and, more than that, it’s at the root of all that is wrong with the HSE. According to its most recent annual report, the HSE gave out €4bn in grants to other organisations, all of them (and there are hundreds) providing health and social services.
In the vast majority of cases, those grants are covered by what are called service-level agreements.
They are effectively binding contracts — and they impose minimum standards of governance on the organisations receiving the grants. (Although it’s clear from the most recent annual report that they don’t always get this right, even.)
They give the HSE the right to audit, to monitor performance, to demand regular reports, even to insist that there is a proper system of governance in place.
That’s all as it should be. But the HSE constantly fails to apply the same standards to itself. And that’s a major part of the reason why nothing ever changes.
The Minister for Health, Simon Harris, has promised to put a new board in place. Sometime.
But, in the meantime, if his Department goes ahead with the appointment of a new CEO and with the same processes of accountability that exist now, the rot will simply continue.
In short, sacking Tony O’Brien might make some of us feel better. But it will achieve nothing.
I’ve written here before, many times, that the HSE has to be broken up. But, first of all, it has to be governed properly.
That’s why, if I were the health minister now, I’d take a leaf out of Tony O’Brien’s book. I’d pause, with a view to ensuring that this must never happen again.
The minister should not appoint a new CEO. He should put a really senior board in place immediately, and its chair should be tasked as an executive chair, with an 18-month to two-year remit.
The new board should also be told that its job is to replace the HSE with a structure that is properly accountable.
Ideally, that should mean breaking the HSE into much smaller entities, even if they all continue to operate under the umbrella of the HSE.
Four divisions — a Hospital division, a mental health and disability division, a community services division, and a primary care division — make sense to me.
Of course, other divisions are possible. Internal agencies, in many cases buried deep within the bureaucratic heart of the HSE — like the National Screening Service, as a prime example — need to be established as stand-alone public agencies.
The independent board of the screening service was done away with, and it needs to be replaced. The principle needs to be that no agency is allowed to report to itself, or to operate in secret.
Each division should have its own Board and management team, including a CEO. There is no need to recruit new managers — people should be promoted from within, on the basis of three-year contracts, with searching reviews of performance at the end of that period.
We’re going to hear an awful lot of guff in the months ahead, in discussing who should replace Tony O’Brien, and about the need for reform.
But reform will never happen unless it starts. That’s why the time to do it is between CEOs — there is a highly paid management team in place to keep the show on the road, in the meantime.
A board with a mandate for nothing else except reform has some hope of success. A new CEO, who will immediately be engulfed by all the operational crises that are part and parcel of this disfunctional organisation, has none.
The HSE was established, at least in part, to deflect political responsibility away from ministers. But, in its dysfunctionality, it has become one of our biggest political issues.
Fundamental reform is both vital and critically urgent. And we know this for sure.
If it isn’t fixed now, by decisive political leadership, we will all regret it for years to come.
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