We must separate management and administration

One of the issues facing the Irish health service is to separate the management and administration career streams, which have totally different challenges, HSE Chief Executive, Cathal Magee told the HMI Annual Conference.

Cathal Magee
Cathal Magee, HSE Chief Executive

Speaking on “The Challenge of Health Service Reform,” he said we tended to confuse management and administration.  Administration was a required core competence for the effective running of the health service, we needed superb back office administration and we needed to develop our administrative capability.

We also needed to strengthen the management system and grow our future management.  We needed significant investment in management as a strategic priority and we needed interim solutions as we did not have the luxury of growing future senior managers over the next three to four years.

We needed significant investment in management as a strategic priority and we needed interim solutions as we did not have the luxury of growing future senior managers over the next three to four years

We also needed to define management in our health system and where, medical, nursing and allied health professionals came into the debate.

At executive level, the key opportunities and challenges were to bring clinicians into a management role. Very significant progress had been made recently with the evolution of clinical directors.

“Clinicians must be at the centre of re-engineering and management and management must be a core part of clinicians’ development.  We need to create and support an enabling environment and develop co-leadership models.

“Clinicians must be at the centre of re-engineering and management and management must be a core part of clinicians’ development.”

“What Dr. Barry White is doing in relation to the development of National Clinical Programmes is a great example of the emergence of clinical leaders in our health service.  A new cadre of clinical leaders is emerging who are blueprinting what is needed. A big challenge is to move now into the implementation of the clinical programmes and to encourage clinicians to stay with the implementation agenda, which is quite challenging because of the resource problems.

Setting the context for the current reform programme, Magee said the population had increased by 17 per cent since 2002, the over 65s costs were expected to increase by two per cent each year for the next five years, the number of adults with chronic conditions was set to increase by 40 per cent by 2020 and invasive cancers were projected to increase by six per cent annually for females and eight per cent for males.

Between September 2007 and this year the numbers of management/admin staff had been reduced by 12.78 per cent

The demand for acute and non acute care was continuing to rise and incumbent models of care were struggling to keep pace.  The HSE had three objectives – to improve access to care, to improve the quality of care and bring down the cost of care and these had to be done simultaneously.  The SDU would begin to tackle access and the elective waiting list and then the outpatients waiting list.  Improving access was a huge challenge but quality was also very challenging and the suite of clinical programmes had been developed to improve quality.

Public health expenditure as a percentage of GDP had increased just over six per cent in 2001 to 9.66 per cent in 2009/2010 and had dropped to 8.99 per cent this year. HSE funding had been coming down since 2008 and there had been a particularly significant reduction in 2010, when almost one billion of cost reductions had to be effected, and this was set to continue.

Comparing our total health spend per capita with some other European countries, Magee said  that 2011 OECD data showed that in 2009 we were spending 3,781 US dollars per person, compared to 3,487 in the UK, 3,722 in Sweden, 3,978 in France, 4,218 in Germany, 4,348 in Denmark and 4,914 in the Netherlands.  It had also to be remembered that the Irish data included social expenditure which is estimated at 20 per cent of total health expenditure.

He said health is a people intensive business delivered through people.  This year, 35 per cent of staff were nurses, 15 per cent health and social care professionals (which is a very significant increase), 15 per cent management/admin, 10 per cent general support staff and 17 per cent other patient and client care.

The existing HSE operating model was too centralised – service delivery required local leadership

The number of management/administrators in the health service had increased from 14,714 WTEs in 2001 to 18,421 in 2007 and then dropped to 16,066 in 2011. At present, 43 per cent were clerical officers, 27 per cent Grade 1V, 17 per cent Grade V or Grade V1, six per cent Grade V11, four per cent Grade V111, two per cent were general mangers and one per cent senior managers.

About 8,000 people had come out of the health services in recent years and the numbers employed were now about 98,000 which is about equivalent to 2004 and a further drop of 6,000 was projected by 2014.  The numbers who had left and who would leave had implications for the services and presented new challenges.

Between September 2007 and this year the numbers of medical/dental had fallen by 1.34 per cent, the number of nurses by 7.14 per cent, health and social care professionals had increased by 2.7 per cent, management/admin had been reduced by 12.78 per cent, general support staff was down by 19.88 per cent and other patient and client care staff were down by 4.32 per cent.

Turning to the National Clinical Programmes Magee said they would be delivered by clinically led multidisciplinary teams, with a structured programme management approach.  It was planned to nationalise existing best practice, engage patients, align stakeholders, make data drive decisions and local ownership of implementation.

He said the existing HSE operating model was too centralised.  Service delivery required local leadership.  Huge progress had been made in moving out management responsibility to the four regions.  But we needed to go further.   There had to be “ownership” in the frontline and the frontline had to be connected, responsive and authoritative.

“The Minister talked about turning the organisation upside down and in many ways we have to unbundle and invert.  We can’t think about a hierarchical organistion.  Our front line delivery units are a critical component.  We can combine them into networks and government needs to take the key decision as to whether they will be hospital or health care networks. Then we have the question of enterprise support and shared services.  There are huge opportunities in centralised purchasing, but it should not take away from the autonomy of front line operative units.

“We must also consider the question of sustainability in the face of the current economic challenges. How do we sustain delivery, how do we come through very significant reduction in people and money.  It is the pace of these reductions which is particularly challenging.   We need to ensure that everything we do is about improving our health services for patients and clients and we must not be distracted by things which do not feed into this.

“The real challenge over the next three years is to be focused on changes that improve front line delivery of care to our patients.  The traditional steps to reform won’t work because they will take too long, so we need almost concurrent parallel cost control programmes, national clinical programmes and the SDU, all built on those lines.  Finally I think it is about creating the right conditions in which people can get on with the job.”