No organisation in Ireland is quite as unique a shambles as the HSE Here is how to fix it.
The problem is that 20000 staff out of around 100000 are utterly incompetent, many are admin staff ( not all). The HSE long had a culture of dealing with bullying and incompetence by PROMOTING these muppets out of the firing line. It is top heavy with obnoxious and incompetent senior staff.
So you transfer all the competent staff INTO hospitals while transferring all the muppets OUT TO the HSE and ‘management’ and ‘policy’ and medical card issuing.
Then contract out the medical card issuing quick like and shut the rest down overnight a la Anglo and make the HSE staff all redundant overnight leaving only the hospitals and their staff working on.
Then found a new ‘management’ body and hire competent managers from day one and transfer some of the competent ones back from the hospitals too. You’d probably run the HSE with no more than 2000 competent staff as distinct from the 20000 muppets parked on theri arses all over the health system nowadays,
Finally the consultants. Private contracts should be abolished overnight, if a consultant wants to do private work let them go private or else they just work for the state in a hospital. No long winded negotiations with them, simple year zero stuff. Also put a lot of the work into REGISTRAR led teams as the other problem in teh Health system is that there are not enogh consultants (even if they were in the bloody hospital instead fo doing private hours) and the whole system is frozen waiting for them to authorise work.
As there are only 3 regions and in effect only 5 regional hospitals in Ireland ensure that sufficient registrars exist to act as locums in the outstation hospitals, so if there is EG one surgeon in Letterkenny let a registrar from Galway cover for them when they are on holidays. Also ensure each consultant in an outstation does 2 weeks in Galway every year to keep their skills up with the specialist types in their field as well as get to know the registrar pool in their region.
Oh, and hire more consultants, we still dont have enough.
As for junior doctors, limit the work week to 65 hours and to 220 hours a month ( and with no more than 3 months at 200+ hours and with the rest of the year at 200 hours max ) and pay them their overtime like is right. Also double every medical school intake in Ireland overnight.
And that is the problem. It is way more complicated than acute hospital deficits and medical cards. I do like the detailed pay cost analysis that is differently analysed between classifications of pay and staff numbers But that is a trivial complaint. The whole thing should be privatised on tender. Of course that won’t happen. Harney realised that it was easier to replace public with private - which is way more efficient - than fix the public health service. That is the unfortunate reality and the acute hospitals are only a part of the problem.
Unfortunately O’Reilly has taken huge steps backwards by trying to kill the HSE and go back to the old model, thus bringing in the worst of both sides. As can be seen the main net effect of this is a massive overspend as the limited controls that were in place have now evaporated and nobody knows least of all. Witness Tony O brien last week doing a comical Ali twostep on the budget figures, I mean what the hell did he think would happen ?
I am repeatedly reminded of a talk by a health economist I saw several years ago (HSE had just been born) where he had mapped how several health systems in Europe are organised and studied the success/failure of reform programmes. There was no particular trend from an organisational point of view - some were in the process of centralisation; others were in the process of decentralisation. Neither was inherently superior to the other.
The main trend he observed was that everyone reckoned their system was imperfect so tried to fix it by changing the structure. Then, when that didn’t deliver within a couple of election cycles, they tried to undo it. I’m paraphrasing but the conclusion was that it takes a least three years after reforms are completed for the system to be back where it was (i.e. the pain and cost of the reform actually makes services worse for several years) and only then is there a chance to make things better.
Ireland reckoned having 11 health boards led by the Dept of Health was the problem so the boards were scrapped and policy execution handed to the new HSE - but, crucially, without cutting jobs. Then they thought this was a bit insensitive to local needs so they set up regional health forums. Now they want to scrap the HSE.
10 years from now a new government will hit upon the ingenious idea of finding efficiencies by centralising health services.
Much like the recent Seanad debate the Health Boards to HSE debate was very centred around booting out some politicians out of handy jobs as opposed to anything more cerebral or taxing. Similarly, some of the current debates around PS reform seem to be about how much pain can we claim we are dishing out to certain disliked groups. Not saying that reforms aren’t necessary but when the debate is based on emotions (and sometimes emotions whipped up against certain groups) the chances of a positive result is mixed. I have been told that there is widespread knowledge that certain reforms currently being applied will be harmful but that the media effect of being seeing to bash certain groups means they will go through. Are there any adults in the audience?
Bureaucrats are necessary if you want to avoid having doctors and nurses spending half their day buying medical supplies from Alibaba and issuing private health invoices using Paypal. What you want is effective bureaucrats.
Putting aside Ireland’s legacy issues, the problem is that modern healthcare presents some intractable challenges. Most punters want their taxes spent on effective front-line treatment, but vast resources are spent on treating conditions that are both preventable and curable with lifestyle changes.
If you task a blue-sky-thinking bureaucrat with improving effectiveness of spending, they may end up producing a website with lifestyle advice (the modern equivalent of leaflets in the GP surgery) rather than buying more drugs or whatever. Then nobody takes the advice and you end up with the same number of COPDers and diabetics and a bunch of expensive websites.
Christ knows what the answer is. I can think of lots of solutions, but most of them involve involuntary euthanasia.
What I do know is that anyone who thinks there should be more clinicians in health service management needs to look at the walking disease that is Dr James Reilly.
Worse, we now see DPER and D Taoiseach having oversight roles on Dept. of Health budget . It is telling that the HSE is being blamed when O’Reilly has made every possible effort to kill the HSE and bring all the strands into Hawkins House.
Now we will see the handwaving in D Health blaming DPER for the cuts ( everyone is conveniently forgetting cabinet solidarity , i.e. there is only ONE goverment not two blames. O reilly is either in the Cabinet or he is not ) The senior mandarins in health must be appalled, in civil service terms this means you’ve lost huge face ( i.e. couldn’t manage own ship )
I’ve always thought one implementable change would be centralised procurement for common items. Eg sheets, batteries, IV fluids, dressings etc.
Instead of each hospital tendering and negotiating with suppliers the HSE takes this on negotiates discounts and contracts at a state level.
The NHS has NHS Supply which performs a similar roll.
That would move the bulk of the purchasing dep out to a new entity, and should reduce the number of staff and cost of goods. Of course you would have to have job losses to make it work but that is not the way we do things in Ireland.
Paediatrician Prof Michael O’Keeffe sez Bring in Ryanair Boss
**“He is exactly the sort of person we need in this health system. We need a guru to come in and shake it up and say ‘we’re not taking any more nonsense’. He’d have to take on the doctors, the nurses, the porters, every single group. But that is what needs to happen otherwise we will keep on throwing money at it and that won’t work.
He also called for the HSE to be scrapped and for the Minister for Health to step up and start making decisions.
Prof O’Keeffe said he was one of the few doctors who had not signed a contract prohibiting them from speaking out and he was happy to blow the whistle.**