What is needed in the Irish health services now is the hard slog of implementation rather than big ideas, Michael Scanlan, Secretary General of the Department of Health and Children tells Maureen Browne.
If Michael Scanlan, Secretary General of the Department of Health & Children had to choose three words to describe how the Irish health services could best be improved over the next couple of years, they would be “Information, Information, Information. We need better information on how money is being spent, on the people working in the services, where they are working and on activities, outputs and outcomes. We are getting a certain amount of this for hospitals but we need to drill down now to get it from the community services and other areas.”
Scanlan, who is just completing five years at the helm of the Department, believes that we have developed the vision for the future development of the health services. “It is the hard slog of implementation rather than the big ideas which we now need,” he says.
We are not good at disseminating best practice and innovation in a systems wide way
He believes services are our core business. “I use the term ‘business’ advisedly, although some people may react against it. I am inclined to look at health as a business with the patient and not profit as the bottom line. The core of our business is to provide clinical services, so I think the work of clinicians offers the best chance of improving our services.
“The Public Accounts Committee recently raised with me the question of access to services – something we have been discussing with the HSE. We have reasonably fast access to GPs (which is not as good in Canada and other countries as it is in Ireland). Then we have to look at how long it takes to see a consultant if the GP refers and how long it takes to get treatment if the consultant decides this is necessary. I think the problem is the piece in the middle – the time it takes for consultants to see patients referred from GPs. There are over three million OPD attendances each year, the majority of them returns. The HSE has been working to improve the ratio of new to return cases and I believe there is a great potential for a lot of return patients to be cared for in primary care. This depends on how clinicians do their business.
“Much of this comes back to information. We are not good at disseminating best practice and innovation in a systems wide way. I think the best way forward is to let clinicians know what they are doing, what their peers are doing and give them a toolkit of different ways to improve how they provide services. One way will not always work – of course there are huge differences between big Dublin hospitals and smaller ones in other areas of the country. What I would like to see is that we say this is how others are doing it and then let people go away and see what works for them. Of course, if given this help and support they make no move to change and improve we would then need to look at taking other action but I would hope this would be unnecessary.”
Three years ago when Scanlan addressed the McGill Summer School in Glenties, he warned that one of the problems was that we tended to measure success by the additional money received or the additional people recruited, rather than focusing on what was done with the money and how the services were delivered.
“I still feel the same way. The challenge now is that we have less money than expected. We have less this year in absolute terms and for the foreseeable future it is likely to be less in real terms. The challenge is to protect and improve services for patients with the money we have. For example, the Department and the HSE have made good progress in saving money in the costs of drugs which can be redirected into additional services.”
He sees the re-organisation of cancer services as a good example of the transformation programme. “The cancer strategy predated the HSE and the arrival of Prof. Tom Keane, but I don’t think it could have happened without them. It’s a good example of how people can come together to make changes happen. The HSE, the Department, Prof. Keane, clinicians and politicians mutually supported each other. In the past clinicians might advocate change and politicians oppose it or politicians might propose change and clinicians oppose it. In this case it was a coming together with mutual trust.
“The evidence to support the link between volume of services and survival was almost incontrovertible in cancer and while it might not be as clear in other areas there is generally good evidence to support the need for changes in clinical practices. That is what Dr. Barry White, the new HSE National Clinical Director, and his team will now be doing. They will be selecting other disease categories and developing better ways of delivering services to patients. I see them establishing a team of clinicians to see what can be done, to share information and then move forwards. I think this also works well for staff. For example, I believe staff working in the cancer area are now happier and more motivated: there is more structure and less of what I would term ‘chaos’ in their day to day work since the change.
He sees the roles of the Department of Health & Children and the HSE as intersecting circles
“Over the past few years there has been more debate about how to do things differently and I would give Prof. Drumm a lot of credit for this. I think the health services are now further down the road of asking these kind of questions than other areas of the public service. I would also like to think that people are willing to accept the arguments for change, if the reasons are clearly set out and we will need to do more of this if we are to make the necessary changes in outpatient and primary care services.”
Scanlan believes we are looking at “transformation” as if it was a big change that would happen in a certain number of years and then be finished. He sees it as ongoing and, while it may appear slow, it will effect change. He cites primary care teams where initially there were great strides with ten pilot PCTs, but then the programme stalled, now it is unlocked and happening again.
He sees other successes such as the Fair Deal; the inspections started by HIQA; the increasing number of home care packages; the evidence that more people are getting services; the reduction in the number and duration of admissions for mental illnesses and the number of involuntary admissions and the inclusion of mental health in primary care teams.
He believes that our policy goals on disability are not sufficiently clear – there is considerable work being done but it is difficult to measure and not all disability services – such as housing and independent living – fall within the responsibility of the HSE. We need to establish precisely what we want to do and specifically how we expect to get it done. The new Office for Disability & Mental Health in the Department is tackling these issues.
Asked about the specific roles of the Department and the HSE he says he sees them as intersecting circles.
“The view now is that before the establishment of the HSE, the Department was responsible for the delivery of services. Of course it wasn’t, it was responsible for policy, regulation and funding, and in providing funding the Department was involved in performance management. The Health Boards delivered the services, although when it had the Vote the Department was more involved in how, for example, new service should be delivered.
The fact that the HSE has the Vote provides greater transparency and means we can have a more honest debate
“The HSE is primary operational and the Department primarily deals with policy and evaluation. But there have to be close linkages – it is very difficult to write policy without consultation. Many of the successes I mentioned are a result of good collaboration between the Department and the HSE.
“Legislatively, it is the Minister and the Department that negotiates the annual estimates. It is the Minister who reports to Government, and the Department which reports to the Department of Finance, twice a month.
“Some people may believe that not having the Vote makes it more difficult to effect change. Ultimately, however, I think that the fact that the HSE has the Vote provides greater transparency and means we can have a more honest debate. It has also been a learning curve for the HSE which has had to deal with Vote accounting as well as accrual accounting. We have worked well and hard with the HSE to achieve this transparency. We now have separate sub-heads for development funding, demand-led schemes and the Fair Deal. Again, it is better information about money, and how money is spent.
“We need greater clarity on where we and the HSE should focus. One of the weaknesses in the past was that for a variety of reasons when the Department developed policy it was not always explicit about policy goals. We have a big responsibility to be clear as to what we expect the HSE and other agencies to deliver.”
Michael Scanlan has been a public servant since 1973 and is proud of it.
“I would like to get to the stage (and I know this is difficult) where people working for the Department and the HSE would again feel they could take pride in their work and feel valued.
“I think that as public servants we are not good at communicating what we have done while retaining the ability to be self-critical and being adult enough to accept criticism while not devaluing what we do.
“Traditionally the Minister communicates – and that is as it should be in a democracy. But one of the drawbacks is that as a group of professionals we do not communicate what we have achieved.
“I haven’t loved every hour of every day in my working life, but I have never been bored. People working in the public service can do many different kinds of job and get great job satisfaction without moving employment I think it is the ability to do good which drives most people in the service. I’m not saying they have a higher moral standard but there is a culture of the public good which does imbue people in the service.”