If you accepted the job of running the HSE tomorrow, what would be your number one problem?
Well, after perhaps getting your head examined, you would find the clue would be in your job title - it's the HSE you would have to run.
After nearly two years in charge, Tony O'Brien admits that the controversial behemoth that replaced the health boards in 2005 has major internal flaws and a poor public image.
In an interview with irishhealth.com, the Director General is adamant that the HSE is getting its act together under a number of headings. He is positive that the planned reforms, including the abolition of the organisation he heads up, will lead to a better organised and run health service.
The former head of the National Cancer Screening Service and Department of Health Special Delivery Unit took over the HSE following the surprise departure of Cathal Magee in July 2012.
Since then, he has faced the challenge of steering the organisation through 'doing more with less' as budgetary and staff cuts continued to take a very heavy toll on the provision of care.
His time in charge, like that of his predecessors, has been punctuated by concerns over how the HSE performs following continuing patient safety scandals, revelations over top-up pay, medical card withdrawals and many other issues.
Like any head of the HSE, he has his critics, but overall he is regarded as a 'safe pair of hands' at a time of challenge and change. He has a tendency to descend into somewhat impenetrable admin-speak, eg. 'downward upper employment ceiling', but shows a good understanding of how his organisation functions (or not, as the case may be) and what needs to be done to make it better.
He also has the distinct advantage that the problems he is now trying to deal with and their consequences are largely legacy issues presided over by his predecessors and successive Governments; so in other words, most of it didn't happen on his watch.
Tony O'Brien appears convinced that we are heading towards an improved health service. Many would feel that the most positive development as we head towards new health structures is that we won't have the HSE to kick around any more.
The HSE's poor image
Tony O'Brien says there is no doubt that the HSE has a negative public image. "It's negative because from the moment it was established, every act, sin of omission or commission by every health board or health entity that ever existed before was immediately labelled as relating to the HSE. Even now you hear about stuff the HSE did or didn't do in the days before it was established.
He says the manner of the HSE's creation was 'sub-optimal'.
"It happened very quickly and with the benefit of hindsight, too many things were pushed together too quickly without enough attention or time to be paid to fundamental issues that could have changed the characteristic of the health service."
"There was no time to prepare appropriate integration of systems so even now, the HSE has great trouble producing national data on a number of things, even basic financial data. The merger of health boards happened under circumstances where it wasn't possible for the organisation to ‘de-layer' itself. The amalgamation created additional layers of bureaucracy which have taken a long time to reduce, and that became quite paralysing for the organisation. Many people inside it felt disempowered, unable to do their best work and as a result the high expectations created for the HSE were very quickly dashed."
Still too many administrators?
Tony O'Brien believes the public perception of the HSE as being top-heavy with admin staff, even after the recent reductions, does not give the full picture.
"There have been very significant reductions in administration staff. It's important to be clear about what we actually mean by admin staff. Clerical or management admin actually includes a lot of things that aren't really in that category. There is a range of specialist staff, for example, the staff who check you in to an outpatient clinic who would be classified as admin, the staff who answer the phones and assist people with medical cards - things which are really customer-facing - are classified as management and admin, and many clinical staff will tell me they are suffering from a shortage of the appropriate skill mix in this area which would enable them to do their best work."
Tony O'Brien believes the HSE has suffered from the arbitrary nature of staff downsizing through voluntary exit programmes, which have not targeted particular areas but have been available to all grades and types of staff.
"It's been entirely unstructured, a fairly blunt instrument. Quite a lot of staff have exited under these voluntary programmes from areas which have been development priorities. It has been entirely self-selecting- no commercial entity would ever downsize in that way."
The Director General suggests that some HSE services could be outsourced, to allow key permanent staff to concentrate on priority areas.
"What I'd want to do is look at those activities that we are currently using staff for that could potentially be done by other service providers outside the HSE, and then use the staff we do have for things that need to be provided as a core part of the health service. If the absolute freedom existed to do so, I would prefer the clerical and admin staff that we have left to be doing things that directly support patient care, customer interaction, the medical card scheme, health promotion etc."
"Some of our accounts payable functions, for example, basic back-office financial transaction processing, could potentially be contracted out to other service operators. Our financially qualified personnel, for example spend a disproportionate amount of time doing this, rather than doing more decision support work. Obviously in saying that, there are provisions under the Haddington Road Agreement which would stipulate that very specific processes would have to be gone through, so I wouldn't want to give the impression that I'm about to outsource a whole raft of functions without due regard for policy, but these things can be done in certain ways. As part of the overall reform programme I feel it is something we definitely have to look at."
Tony O'Brien rejects suggestions that the structural reform process leading to the introduction of universal health insurance lacks clarity and risks creating additional layers of bureaucracy and 'quangos' in the health service.
"No, I think in the immediate post-HSE phase, it's clear there will be seven hospital groups, and a certain number of community health organisations. They will all be commissioned and funded through a Healthcare Commissioning Agency. Then there will be the Department of Health, various regulatory bodies, and a new patient safety agency. I think there is a relatively clean diagram of what the entities will be."
Is there a danger here of going back to the pre-HSE health board system, with a multiplicity of bodies running things?
"No, I wouldn't agree. The hospital groups, for example, are nothing like health boards. With the advent of the clinical programmes, with hospital licensing, with standards for safer healthcare, it is very clear what each hospital group has to do and how it should do it. In terms of how they organise resources within the group there will be more freedom, but they're not comparable to health boards."
"There's a view, which I would agree with, that the HSE as a single construct is simply too big to be effective, and to move away from one thing that's too big you have to have several other things that are less big. All of these changes would be appropriate whether or not we were heading to UHI."
Universal health insurance
Tony O'Brien is reluctant to comment on concerns about the possible costs of universal health insurance (UHI) and if a purely taxation-based NHS type system would have been preferable.
"I have never made any secret of the fact that I am a strong personal believer in the principle of universal healthcare where access is based on need and not economic means. The only way you can get there is either by an NHS-type model or a universal health insurance type model. Both of them appear to be reasonably valid models. Under either model the one thing that's clear is that it's the people of the country who are paying for the healthcare, there are just two different routes of doing it. I'm in no doubt as to the degree of commitment of the Government to moving on the road to UHI."
He will not be drawn on which system, UHI or NHS-type, he would prefer, as this, he says, would be commenting on the merits of Government policy.
Impact of cuts
The Director General is candid enough about the impact of year-on-year health cuts.
"Given the upward trajectory of demand and the downward trajectory of resources, there is going to come as time where the bottom has been reached. Some argue that we may have reached that bottom already."
"I don't believe that staff numbers in the health service can be reduced very much further, if at all. For example, in the maternity area, we are going through the 'Birthrate plus' exercise - we will be looking to benchmark the appropriate staffing and appropriate skill mix in different services. There will be variable answers, some services are better staffed than others, some are understaffed."
He is particularly concerned about the impact of the employment ceiling and recruitment restrictions that have been a feature of the health service in recent yerars.
"I would be concerned about the impact of headcount limitations on the health sector for two reasons. One is that you can't really have a never-ending downward upper employment ceiling unless you have tested and ensured that the 'floor' level is also correct in terms of the basic numbers of staff that you need for each service that are necessary to meet the needs of the population. The staff numbers that we have had haven't been derived from that type of an exercise."
"When you have an arbitrary number of staff that decreases year on year and is determined by a process that isn't fully connected to need then it is essentially a crude process. The 'grace period' exit programme which occurred in early 2012-led to a 5% downsizing of the HSE pretty much on a single day. No manager or policy-maker was able to sit down and said this is where we need to reduce staff numbers, it was a case of ‘put your hand up and you go'. The net effect of that is that a huge amount of institutional memory - experience and skillsets - was lost from the organisation."
Tony O'Brien believes that this type of exit plan by its nature tends to promote the exit of people who are at the most experienced end of their careers.
"As a result, many units in the organisation, but for the deployment of temporary staff at great expense, would have ceased to function. We have seen an increased reliance on agency personnel which pushes up the cost of labour, introduces instability into the workforce, and all of those things are known to have an adverse impact on the overall quality and cost of the health system. The Government has now put back what would have potentially been a further exodus this year, through a further 'grace period' early retirement scheme. I would be in favour of having a degree of discretion on both sides, where people can volunteer to leave but there can be no automatic right to go."
He stresses, however, that there has not been a complete recruitment freeze in the health service.
"It's not an absolute freeze. It's a ceiling above which you cannot go. So we are actually recruiting. In the context of current reforms I would hope that arrangements can be made so that the very large numbers of staff, particularly in the nursing area, who are currently in agency employment but substantially working for us at higher cost, that we could arrive at a situation in which we could convert those into regular long-term temporary staff. In this way there would be more stability for them, a better employment situation for them, and it's likely to increase the quality of care provided through the benefits of consistency."
Safety of services
With reviews of the future organisation of maternity services nationally and emergency department services in Dublin now underway, Tony O'Brien admits that not all of these services will be sustainable in their current form into the future.
"I think there is an underlying issue of sustainability. There are legitimate questions about how we use the resources available to provide the safest most sustainable care, and whether that will require changes to the configuration of services such as maternity units and EDs. I don't see it as a way of reducing overall costs. The number of births we have each year will still have to be provided for. If you are going to have a smaller number (of units), that number will have to have greater capacity."
"By comparison with some other countries it's not that we have particularly small maternity services, it's a question really of whether they are sustainable safely, given the relative unattractiveness of certain locations for staff etc. The ED issue is a little more clearcut. Objectively, for a city the size of Dublin with its current population the spreading out of ED resources, the fact that we have so many hospitals seeking to be both elective (planned care) and emergency admission hospitals leads to the probable conclusion that there is a better way of doing things."
As regards the HSE's ongoing efforts to get to grips with patient safety after successive treatment scandals, Tony O'Brien admits things aren't fixed yet. "There is always more to do. We are acting on Dr Holohan's report into Portlaoise and we are awaiting the findings of the HIQA review."
The Director General admits that he was particularly shocked at the way patients and families were treated and followed up in the Portlaoise scandal.
"Yes, shocked would be the only word for it. 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 and that's why I wrote the letter to all staff in the health service. I felt that there was an opportunity to engage people in a thought process and drawing a line in saying we simply can't do that anymore. 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'."
But is he certain the HSE is doing enough to keep services as safe and quality-driven as possible?
"I believe currently, yes that is the case. One of the challenges we have is that in the past there wasn't a uniformity of approach and I guess we are reaping the results of that right now. The new independent patient safety agency will be of great assistance in helping patients to navigate their way through a complex system if they have issues or complaints they need to pursue etc. It will be good for patients to have access to a team that is there exclusively for them, that cannot be perceived to be in any way apologists for a service that has gone wrong. We will put in place a system that is designed to ensure that when things go wrong, local services, which often at that time are under immense pressure, will be provided with active support and assistance so they can manage the inquiries better.
The Director General believes our hospital system is to a very large extent also our primary care system, and this clearly isn't the right way to go about things.
"We are just doing it in the wrong places. There is a lot of activity going on in very expensive acute hospitals that could well be done in much less expensive community systems, and this would be better for patients, more accessible and more local. I'm in favour of centralising those things where there's strong evidence that you should, but not other things. Ordinarily you would seek to do this at a time when you could put resources into one place in advance of taking them out of the other place. We don't have that luxury as we don't have the money, so we have to find ways in which we can do that on straight transfers, which is challenging."
"Admittedly, hospitals will be reluctant to let go of some of their funding and in truth we need to make sure they are also letting go of some of their costs as they let go of some of the funding. This effectively means that some of our hospitals need to downsize a little bit in order to concentrate on the things they are really good at. The nature of institutional politics is that that will not be pleasant for them, but it has to be done. Some of our larger hospitals are treating patients who shouldn't be in hospital in the first place. "
But the HSE hasn't been very successful in 'selling' an expanded workload to GPs, who are currently up in arms over the draft contract for providing free GP care to under sixes.
"I'm not sure if there really has been a row over the draft contract, because people haven't sat down to discuss it. Minister White has said all these issues can be on the table if people are prepared to gather around one. As regards the issue of not being able to negotiate fees, once we get around the table we can solve these things. In doing we will be taking the first step towards universal GP care, which is an important step in developing primary care."
Top-ups and pay compliance
Tony O'Brien admits the HSE may not have acted as quickly it could have to deal with the lack of pay compliance in Section 38 and 39 agencies.
"I think the extent and the seriousness of the pay compliance issue was exposed by the HIQA Tallaght report in 2012. This changed the game. I would concede, as I have done before, that with the benefit of hindsight it is possible to say more could have been done and should have been done in the past but wasn't done, but we are doing it now. We're dealing currently with about 200 business cases (for retention of extra payments to staff) in section 38 agencies."
He believes this profligacy with taxpayers' money "was a manifestation of what is now a bygone era, a nod and a wink culture and a sense of lack of accountability."
"It's been necessary to bring this to a conclusion fairly rapidly. We can't afford to have this a distraction from the business of improving healthcare."
On the controversy over medical card cuts, Tony O'Brien doesn't accept that there have been 'cuts' per se to the medical card system or that the HSE has been less then efficient at explaining to the public how the issuing of medical cards is now being handled.
"We haven't failed to explain it, but I don't think the message has fully got through. In the past three years there have been some changes to eligibility thresholds. That has affected the basic entitlement to a medical card for some people. The discretionary route to a medical card is founded on the undue financial hardship test - that has always been transacted on the basis of a higher financial threshold than the standard threshold for a card. That's been applied consistently since the recent centralisation of the medical card service."
"As a result of that there have undoubtedly been some instances where medical cards were granted outside of those terms in the past that haven't been renewed or have been withdrawn. But there have been no 'cuts' to the medical card system per se. The medical card system is costing more and more all the time, so there is no cut to the overall level of expenditure."
Then why are we hearing so much about people with special needs or medical conditions having cards withdrawn or downgraded?
"Because they either never did or no longer meet the financial hardship test set out in the 1970 legislation. I accept that we live in a society that would prefer if we had a medical card system that took medical circumstances into account in a direct way, eg, if you have X or Y medical condition that will or won't entitle you to a medical card. There is a certain range of medical conditions where there is probably a societal consensus that perhaps that should entitle people to a medical card, but the problem is that is not what the law says. "
"The 1970 Act allows me to operate discretion in terms of granting medical cards, but it has to be done on an even-handed, equitable basis so that people in a similar situation are treated in the same way and for the moment, this financial formulaic approach serves that purpose."
Tony O'Brien admits that this may be a blunderbuss approach, but says the HSE may change how it operates this system to allow it to be more case-sensitive.
"I've put together a small group to examine whether there are ways of exercising discretion which would be equally robust in terms of satisfying the test of good public administration, to see whether I can give directions to enable discretion to be exercised in a different way."
"I'm also concerned that standardised approaches do mean sometimes that people whose individual circumstances haven't changed at all, can on review when judged against a clear rule set, be deemed no longer eligible for a medical card. This can be very difficult for them to understand if their individual circumstances haven't materially changed, but they maybe in the past were granted a medical card in circumstances where they ought not to have been. So we need to be able to look at ways we might be able to deal with those situations in a more sensitive way."
Ambulance response times
Tony O'Brien, in the face of recent concerns on ambulance response times, says there has been steady improvement in this area, and the data would bear out, "but short of the implementation of the single national control centre and the completion of the current demand capacity review we are unlikely to get all the way where we want to get to, and that clearly is a challenge for us. But it cannot be easily resolved."
"I would stress there haven't been cuts to the ambulance service - it's the one area of the health service that hasn't been cut and where funding has been enhanced. The number of advanced paramedics has increased by 400%. This has been against a background of increasing demand. So whatever it is, it's not as a result of cuts."
HSE may outsource admin work