‘We will devolve as much power as possible’

Mr. Tony O’Brien, Acting Chief Executive of the HSE and the Director General Designate told the HMI Conference that his aim was to devolve as much power as possible within the health system. Maureen Browne reports.

He said there was a widespread feeling that the command and control architecture that was a creation of the HSE, by design had disempowered frontline staff, removed accountability and reduced transparency.  Over time it seemed as if health managers were infantilised to the point where they were trying to self censor themselves in case their decisions were reversed.

Tony O'Brien, Director General Designate, Health Service Executive addresses the HMI Annual Conference 2012
Tony O'Brien, Director General Designate, Health Service Executive addresses the HMI Annual Conference 2012

“Our aim is to devolve as much power as possible within the health system, and to shift the focus from inputs to outcomes, from the centre to the local and from the system to the patients.”

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He said that at an appropriate time they intended to move all the country’s hospitals into similar groupings as the West and Mid West.

“We want all our managers to have the same type of freedom as are envisaged here. We want to de-layer many of the processes that have been developed within the HSE, so that by the time it is replaced we will have simple straightforward processes.

I was never a fan of the HSE, not because of its staff, but because of its structures

Mr. O‘Brien told the Conference that he had been living in Ireland for 21 years and had worked in the public service for ten of those years. “During that time, I spent  time trying to prevent my organisation being subsumed into the HSE. I was never a fan of the HSE, not because of its staff, but because of its structures. When I have finished my tenure of office, the HSE as we know it will not exist.  That is the brief which I have been given. We will make the best of what is in it, repackage it and refloat it. But I will not spend time defending its reputation because I never believed in it.

“I believe I am the least important person in the health service.  The more important people are those who deliver the services every day.

“I am a child of the NHS. I was born in an NHS hospital and my health care in my formative years was delivered by the NHS, so I can relate to the pride of people in the NHS.

“I believe we can build a health service of which the people in Ireland will be equally proud and that is why I took this job.  Most organisations in the NHS operate with a degree of freedom about which many organisations in the HSE can only dream.”

We will make the best of what is in it, repackage it and refloat it. But I will not spend time defending its reputation because I never believed in it

The Director General Designate said that we needed reform because of inequitable access to care (e.g. long delays in ED and on waiting lists), capability and management deficits, inadequate governance and financial systems, challenging financial and HR resource environment, very significant increases in expectations and demand, decreasing funding, unaffordability and an unloved health system.

There was already ample evidence that we could make successful and even sometimes popular changes in our system. Our cancer services were now second to none, which would have been inconceivable four or five years ago. The Clinical Care Programmes had brought huge change in how we assessed care pathways and enshrined clinical leadership in our system.

“This and the SDU show how the revolution is already underway in our system. There was a clear sense of the direction in which the Minister wanted to go. He wanted to take some of the work done before and put it through a new paradigm, which would allow innovation and be patient focused.

If we are going to make hard choices let’s make them at the beginning for the year, see what we can afford and that is what we will be doing this year

The new model of care would improve quality and patient access and reduce cost, e.g. by reducing average length of stay and bed utilisation.

The key principles were that it would be clinically led, clinicians would be empowered to lead the change, there would be a structured programme management approach, existing best practice would be nationalised, patients would be engaged and stakeholders, like patients, government, management, colleges, unions etc would be aligned.

“We want to shift the focus from inputs to outcomes from the centre to the local and from the system to the patient.  These are the hallmark by which this journey must be judged.”

Mr. O’Brien said that the SDU had a strong focus on key  performance areas, a strong political commitment, believed in speedy action, the creation of a focussed team, the creation of a data rich environment, clear milestones and targets and targeted resources.

We had the opportunity to completely transform our health system by provide equal care through a single tier UHI system, providing higher quality care through clinically led, rigorous performance management and a new model of care where treatment would be provided at the lowest level of complexity that was safe, timely, efficient and as close to home as possible.

He said the traditional approach to reform was incremental, dictated by resources and system focused.  The current approach to reform was comprehensive, led by innovation and patient focused.

He said that the annual HSE service plan had resulted in a financial crisis every year. “We are going to do things differently.  Unrealistic assumptions in the service planning resulted in midsummer financial crisis. This drives us to things which are not good for people we serve, for the morale of managers and staff.  If we are going to make hard choices let’s make them at the beginning of  the year, see what we can afford and that is what we will be doing this year.

Where there was persistent performance issues or no confidence that standards would be delivered there was an expectation of change in provider leadership

“With freedom comes accountability.  We will set performance improvement objectives and hold people accountable for achievable progress, supported by data and interventions where people go wrong and escalations, where despite all the help and efforts we provide, improvements are not happening.

”There will be simplified, clearer targets that better reflect the patient journey. Systematic, comprehensive and high frequency weekly monitoring systems will be established. Sanctions and incentives which are an essential part of the leadership challenge, will be clarified and we will hold leaders personally accountable for performance against KPIs.

He said that where providers were on trajectory or there was a high confidence standards would be delivered there would be light touch monitoring, where there were some performance issues or medium confidence that standards would be delivered there would be closer monitoring and elevated concern.

Where ongoing performance issues or there was low confidence standards were being delivered there would be very high frequency monitoring and high concern and where there was persistent performance issues or no confidence that standards would be delivered there was an expectation of change in provider leadership.