In the late 1980s, when Ireland had a straight choice between reining in the public finances on its own initiative, or allowing the International Monetary Fund to do the job for it, one of the quieter line ministers met serious resistance to the spending cuts from his most senior civil servant.
Sensing the threat to government policy, and indeed to his own reputation if he was seen to be house-trained by his officials, the minister concerned sought the advice of a senior cabinet colleague. The two decided on a head-on confrontation to settle the issue.
Depending on who tells the story, the visiting minister either kicked the door off the hinges on his way into the official’s room, or cracked the glass panel as he slammed it shut on his way out following the meeting.
Whither or which, it was a confrontation that would prove to be a defining moment in the life of the new Government, which didn’t want to be seen to flounder like the previous administration, and couldn’t take the risk that external agents might effectively take over the running of the country.
Although, those cuts hit the health services especially hard, at the time there was no alternative. Moreover, the signaling was critically important; the incident proved that the new administration was serious about tackling the crisis in the public finances and rescuing the country from the brink.
I can’t help thinking that the merits of such a tough approach might not be uppermost in the mind of the head of the HSE, as he contemplates how to handle the controversies that are continually breaking around him.
Prof Brendan Drumm is now being damned with faint praise, in particular since the crisis about cancer services emerged at Portlaoise Hospital. Again and again, the comment is made that, while his heart is in the right place and his analysis of the problems besetting our health services is sound, his background as a clinician and lack of experience as a manager leave him singularly ill-equipped to carry through the reform programme.
Drumm’s natural inclination has been to act as a ‘persuader’ for change; and he emphasises structures like the transformation programme to capture the changes he hopes will deliver a different and better health service.
But even he must be wondering if all these attempts at persuasion are getting him anywhere or whether, even occasionally, a little wood-splintering or glass-shattering might focus minds and drive change.
One hand tied
It’s difficult to blame the head of the HSE for the situation in which he finds himself. The trouble is not so much that he has one hand tied behind his back; it’s more that both his feet are nailed firmly to the floor.
Yet as the holder of a colossal €14 billion health budget, he has more power than he realises to impose his will on the body he heads and the people it serves. The HSE will soon have the services of Canadian cancer tsar, Prof Tom Keane, whose job it will be to centralise and rationalise cancer services in line with best practise and to assure equity of access and quality of care.
In this situation, Prof Drumm will have to take a different, more proactive role in selling the changes that are both necessary and inevitable.
Chief among these will be the need to build broad-based coalitions to champion the changes, which Prof Keane will have to force through to assure an equitable, effective service. The new man in turn must be free to pull small groups of the most able medics and managers in the HSE away from their day jobs and into small project teams to implement change fast.
Vision of change
Prof Drumm must also be willing to go over the heads of vested interests, by taking his vision of what will change, why it must change, what people can expect to see and by when, into every living room in the land.
Television is a powerful medium, which politicians use to great effect to inform, explain and persuade, particularly at election time. Yet, surprisingly, the health service never bothers to tap into it in order to present its case.
Communication alone will not address the systemic and structural weaknesses which have resulted, for example, in this country having the third-highest mortality rate from cancer of any country in the OECD.
A better option
Nor will it assuage the concerns of those who legitimately argue that comprehensive centres are a better option than excellence centres, although the latter may be all that is achievable at this time, or indeed may be favoured by Prof Keane as being sufficient to deliver a safe service.
The crisis in breast cancer services at Portlaoise is proof positive of the dangers of spreading a service thin for political reasons. That said, the HSE has a serious challenge on its hands to restore confidence and to persuade people that it can make good on its pledges when it promises change.