Share This Story!

The casualty rate in the race for the top job in the Health Service Executive is looking increasingly like a typical pile-up in the Grand National. Prof Tom Keane was the early faller at Becher’s Brook. One of the Australian front-runners came a cropper at the Canal Turn. The other might not make it over the Chair.

At the rate things are going, Prof Brendan Drumm will be spirited in before the water jump, since there is now no credible candidate to make the running in the final stages. This is quite simply the race that nobody seems to want to win.

I am tempted to add that he or she should start by chopping off the head of the genius that dreamed up the 20 hoops through which a GP referral to Tallaght had to jump, assuming that it had the good fortune to ever be opened. But they would then have to find the genius who apparently believes there should be a national protocol for how GP referral letters should be handled in hospitals.

Why anyone should think that a national protocol for letter-opening is needed is beyond me.

Received and processed

Whether it is Tallaght Hospital or anywhere else, the same, simple sequence should suffice: open the letter, review the request, schedule the appointment and notify the patient.

Considering that mankind put a man on the moon over four decades ago, surely it is not beyond the wit of our health services to ensure that letters are opened as soon as they are received and processed appropriately, within a reasonable time?

And when a backlog of referrals from general practice does occur, why not simply ask GPs to refrain from referring all but the most urgent cases until the list is cleared?

We have heard once too often that the problems in our health service are systemic and that they are not connected to actions by individuals. And yet we have scandal after scandal in the health system – whose budget is now one-half of the entire tax take for the country – underlining the singular failure of the HSE to deliver anything other than a third-world performance from a first-world budget.

Failed spectacularly

But the HSE is only part of the story. If managers and administrators in Tallaght failed so spectacularly, then so too did the clinicians who knew, who had to know, that X-rays were going unreported and referral letters unanswered.

Such ‘systemic failures’ occur, not solely because of a lack of resources per se, but because of the critical, historic failure of our health services to put the quality and quantity of resources that are needed where they are needed, the failure to move them ruthlessly from where they do little or no good, the failure to insist that all employees are responsible and accountable for the resources in their control and the failure to properly protect those who blow the whistle.


Despite quadrupling the health budget in just ten years, the quality and equity of our health services remains as mysterious as the elusive Higgs Boson. Many have simply given up on the public health system at this stage, opting instead to retain private health cover, even as the most serious economic crisis to affect the country in half a century hits household incomes hard.

It is hard to blame people for believing and behaving as they do. The public health service has been put in this place by itself. Parse it how you please, but so long as there is neither reward for calculated risk-taking that returns more from less, nor consequence for inaction or incompetence, such ‘systemic failures’ will continue.

The great problem with many of the measures in the latest round of reforms for ensuring, once more with feeling, that ‘this kind of thing never happens again’ is that ring-fencing specific responsibilities to particular individuals effectively signals to everyone else that they are essentially absolved from playing a part in resolving problems rooted as much in mistrust as in mismanagement.

Better-managed hospital

In theory, a smaller, skilled board of management to which a broad-based, representative hospital board would effectively defer, should make for a better-governed, better-managed hospital.

In theory, the inclusion of people with business and financial skill will bring greater rigour to the way things are done.

In theory, the post of Director of Quality will ensure, among many other things, that X-rays are reported and patient referrals are dealt with appropriately.

In practice, politics and old ways will get in the way, while a perception that recommendations have been acted on, or assigned to someone to act on, will signal that the problem is solved and all is well once again.

If that happens, the deeper cultural shift that is required will be viewed as no longer necessary, making systemic responsibility and accountability as elusive as ever.

Roles clarified

The Minister says she will welcome any steps that can be taken to improve the governance of the hospital, so that roles are clarified and procedures streamlined. But she herself has been far too fond for far too long of describing scandal after scandal as ‘unacceptable’, while quietly washing her hands of political responsibility.

She has colluded willingly in a calculated, protracted, systematic destruction of the doctrine of ministerial responsibility, where accountability can be assigned anywhere, so long as it is not the Minister’s office.

Minister Harney is not expected to micro-manage the health service; in any event, that is the job of management and staff in the local setting – though some occasional macro-management from Hawkins House would be useful when a national approach is called for and people need to feel reassured that someone is in control.

Solving problems

Partnership ought to be the means for solving problems in the local setting. But the partnership project has atrophied because its problem-solving potential is and always was subservient to the participants’ power of veto. Thus, responsibility and accountability, which properly belong to everyone, in reality belong to nobody.

We will never know whether Prof Tom Keane could have achieved throughout the health service what he managed to pull off in cancer care, but whoever takes the tiller will face the enormous task of delivering far more from much less.

Encouraging a can-do approach, creating an honest partnership that solves problems rather than creating them, and providing adequate protection for those who blow the whistle either privately or publicly, are all essential.

The fear of losing one’s job, or of being denied a promotion, or of being isolated, all too often prevents people speaking up when they see poor care, substandard service delivery and resources wasted.

A more open, responsive, accountable health service demands they be heard with respect.