Health managers need evidence based competencies

Grade drift, “tapping people on the shoulder” for appointments, poor morale in the health service and the timescale for implementing the new Acute Medicine Programme were among the topics raised at a lively debate at the packed HMI Forum in Ardee.  Maureen Browne reports.

HMI President, Richard Dooley called for evidence based competencies for health service managers at the debate at the HMI Forum in Ardee.

Maureen Browne
Maureen Browne

He said “It is up to managers and the HMI to re-assert managers’ confidence in their role and accountability and to give them credibility and authority.

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“Grade drift has happened because we do not have evidence to say that managers are competent to manage at different levels, what is expected of them at these levels, what is expected of those they manage and what is expected of those to whom they report.”

He said the new transformation would affect all managers and would require leadership at local level and challenging prevailing management ideas and clinical assumptions.

Concern about grade drift, “tapping people on the shoulder” for appointments and poor morale in the service were also raised at the debate.

The new transformation will affect all managers and  require leadership at local level and challenging  prevailing management ideas and clinical assumptions

Pat McLoughlin said that there had been a dumming down of grades in the health service.  In the private sector, middle managers took much more accountability and responsibility.  The health service was complex and highly unionised and senior managers probably made themselves too available to take decisions that should be taken further down the line.

Image tarnished

He said they had allowed grade drift and the image of managers had been badly tarnished.

“We didn’t defend managers in the former health board system.  Most managers are self-starters and, as a result, there is no proper evidence based competencies out there for managers.   We need to hear people talking about ‘top managers’ like they talk about ‘top consultants’ ”.

Denis Doherty said staff needed to be empowered.  It was John Fitzgerald Kennedy, who said that in the Vietnam War the important decisions were not taken in the Pentagon, but by the GIs up to their waists in the paddy fields.

The important decisions were not taken in the Pentagon, but by the GIs up to their waists in the paddy fields

Martin Cowley, former CEO of the Mater Hospital, Dublin asked if anything could be done about grade drift at this stage or if the damage had already been done, while Breda Crehan-Roche, Chief Executive of Ability West, said that one of the problems was that there was no benchmarking on what was an acceptable ratio for management and administration.

McLoughlin said that in the days of the celtic tiger, most groups with a good cause could manage to get together sufficient money to get an office, an office manager and a secretary.   Most CEOs were earning in the region of €100,000 and many voluntary organisations were just not in a position now to be able to fund this in the current economic climate. He thought that where state money was being provided, these organisations should receive just what was necessary to do the job and then they could fundraise if they required to finance a more elaborate organisational structure.

McLoughlin said that, as a group, managers needed to put their collective foot down and say ‘no more hands on shoulders’.   Public jobs should be filled by public appointments.

Democratic impetus

“We need to blend the best of the old and the new system.  We have lost key democratic impetus.   If the health boards were in existence when Leas Cross happened, within a month it would have been investigated, the other health boards informed of what had happened and the lessons to be learned and there would have been public accountability.   With the HSE, this took a year or more, but the benefit of the HSE was the ability to implement a national standard for nursing homes which would have been very difficult in the health board era.

We need a more accountable system and I think it was better when managers had to get up in public and answer questions

“We need a more accountable system and I think it was better when managers had to get up in public and answer questions.   If there is no local accountability, it goes up to the Oireachtas Committee.   There are systems that will have to be put in place to ensure managers are accountable.”

Asked by Ann Marie O’Grady, Head of Clinical Services, Beaumont Hospital, Dublin about how best managers could grasp the opportunities of the Croke Park Agreement, he said that health had led out in terms of the changes needed in the area of restrictive practices.

“After Croke Park, a key union said they had no difficulty in dealing with the changes, provided they were done by negotiation.   This whole thing has been incredibly slow, because the health system is a monopoly provider.    If, for example, Emergency Departments had to compete with each other there would be changes quickly.  However, I think health is on the right track with regard to flexibility, although the road ahead will not be easy.

“We waste so much by not working efficiently.   Some time ago, I had to spend a night on a trolley just to ensure I could get into the theatre to get a procedure done the next morning.  Then when I was ready to go home and had somebody waiting to collect me, they were reluctant to discharge me.  I was ten minutes down the road when I had a call to say I had forgotten my prescription for pain killers. I said I didn’t need any.  A few minutes later, I got a call to say I had forgotten to collect a sick cert for work.  I told them I was due to fly to Brussels for work the next morning.”

Implemented

Former HMI President, Denis Doherty said it should be remembered that those who had experienced grade drift were often most affected by it and this needed to be taken into account.

The implementation plan had now gone to the four Regional Directors of Operations for discussion

One of the things emanating from the Croke Park Agreement was the opportunity for social entrepreneurs.  Managers should ask themselves every morning what would they change in the job that morning.  Would they change the relationship with those who reported to them and the relationship of those to whom they reported?  “We can all give more leadership and make a greater difference than we give ourselves credit for,” he said.

Prof. Shane O’Neill believes that the new Acute Medicine Programme will be implemented because its introduction is being communicated and negotiated properly and, for the first time, people are prepared to bite the bullet and see a major change through.  He believes that the implementation and, subsequently, sustaining of the Programme are crucial to its success.

Replying to Geraldine O’Regan, Director of Nursing at Our Lady’s Hospital for Sick Children, Crumlin, he said that he expected that implementation of the new Acute Medicine Programme would begin fully in 2011.  The implementation plan had now gone to the four Regional Directors of Operations for discussion and the implementation process should start next year.

The implementation plan would take three to five years.

Asked by Martin Cowley, former CEO of the Mater Hospital, Dublin if there were “resisters” around, he said that there were lots of resisters, but also lots of support from people who realised that it would expand choices and options for patients.

Cowley replied that he though it was a very good plan and he hoped that everybody from the Taoiseach and the Minister for Health downwards would support it and not allow people to rubbish it for their own concerns.

HMI President, Richard Dooley asked if there was a potential for clustering any of the new hospital models and if they had looked beyond hospitals to the community. Prof. O’Neill said they would be looking at networks. Networks would provide economy of scale and interdependence and that the new Integrated Service Areas (ISAs) were the real enablers for primary and secondary integration.

Former HMI President, Denis Doherty said that the proposed change represented a welcome joined up approach and a change of culture.  It was also encouraging that there now appeared to a link between best practice and a whole systems approach.