Silence on heath funding must be challenged

The deafening silence on the funding of health and care must be challenged, Mr. Leo Kearns, HSE National Lead for Transformation & Change told the Conference.

Leo Kearns
Mr Leo Kearns

He said Ireland was second only to Greece in real-term reduction of spending on health and out of 53 countries had shown the greatest reduction in public spending on health as a percentage of general government spending between 2008 and 2011. The UK was tenth out of the 53 countries and had actually increased spending on health as a percentage of overall government spending in the same period, he said, speaking on “Transforming The Health Serivces in Ireland, Vision, Values & Engagement.”

However the NHS was heading towards a financial crisis, with the only question whether the crunch would come during the current financial year, which now seemed increasingly likely, or whether it could be deferred until next year. Around two thirds of hospitals there were now either already in deficit or forecasting a deficit at the end of the financial year, while the number of foundation trusts in deficit was unprecedented.

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Don Berwick had said that health spending was on a trajectory to bankrupt nations. It was a problem for government, politicians, the health services and wider populations as to how we addressed this challenge.

We could not take the kind of funding cuts which had been implemented in the last few years when demographics were pressuring the health service.

The consequences were a focus primarily on budget, diversion of critical clinical and management focus, crisis and reactive management, poor decision making, crude control instruments, disconnect between ‘top’ and ‘bottom’, demoralisation, real and worsening impact on patients in ED, waiting lists, delayed discharges and access to therapies.

“Our focus is not to manage budgets but to provide care to patients and while we need a very strong budget focus and budget management it is not our primary focus.”

Mr. Kearns said that focussing primarily on budget had created a crisis situation, led to poor decision making in many instances and the use of crude control instruments to manage this crisis often led to increased rather than reduced costs.

“It creates a disconnect between ‘top’ and ‘bottom’ where care is delivered and this is incredibly damaging. I am sure you wonder if Government, Cabinet and the senior HSE team understand the consequences. Thinking that money and budgets are the primary focus creates a problem of morale for people working in the health services, because they are working for the good of society.

Our focus is not to manage budgets but to provide care to patients and while we need a very strong budget focus and budget management it is not our primary focus.

“We are now seeing the consequences in terms of patient care. It feeds into the narrative that healthcare is a black hole and we can’t trust health to manage anything. But an impossible task leads to inevitable failure and we are building in failure each year.

“A realistic budget for healthcare is one of the fundamental things that has to happen. It will be very challenging for the Minister and I think it may take a number of years to get to where we need to be.”

Mr. Kearns said the health service was not delivered in Leinster House, or Hawkins House or Dr. Steevens’ Hospital, but by clinicians and management in public, private and voluntary organisations and practices and all kinds of settings around the country.

If people were responsible for something then they were accountable for how they dealt with it. But they must also have the authority necessary to fulfil their responsibility and to be accountable.

Hospital Groups and Community Healthcare Organisations were essential to enable the transition of responsibility, authority and accountability to where it mattered. This required the ‘centre’ to change what it did and how it did it. There should be clear roles, governance and management structures.

Mr. Kearns said that without its people, the health service could not deliver on its purpose, to care for patients. Most staff still had extraordinary commitment and dedication to delivering care and support to patients and clients, but many were also disillusioned, under extreme pressure, and wondering about their and the service’s future. Many were also deciding that they no longer wished to work in the Irish health service. We had a problem in attracting management to work in the health service. We needed a culture which was more supportive of people where we listened to what they said.

He said leadership was difficult, but it was only through leaders that we could change things. As John Kotter had stated “Without leadership, purposeful change of any magnitude is almost impossible.”

“We have to see where we stand as regards leadership in the health service and if we have the leadership capability for what needs to be done. The Office of Health Management, which was a very fine organisation, disappeared some years ago. That is what makes what the HMI is doing so important.

We had a problem in attracting management to work in the health service.

Theodore Hesburgh said ‘The very essence of leadership is that you have a vision. It’s got to be a vision you articulate clearly and forcefully on every occasion. You can’t blow an uncertain trumpet.’ I wonder what kind of trumpet we have been blowing recently.

“The first challenge for us is what we believe will be the future of the health service in this country.”

Mr. Kearns said that we must support, listen value and respect the people who delivered the service. We must provide a clear and consistent direction that made sense, ensure that the ‘ask’ while challenging and always difficult, was not impossible, expect high performance from all, support and enable with good workforce planning, succession planning, people development, education and training and we must rebuild trust through integrity and competence.

“People in the health service need clear and coherent direction from leaders. We need to ensure what we were asking of people is possible. We need to challenge people to perform and we need training and development for managers of the future and pretty fundamentally we need to rebuild trust. A breakdown of trust is probably one of the most corrosive barriers to any kind of change.

“I have a lot of confidence in people who work in the health service and I think they can deliver change. Health management is a very challenging profession and not an administrative task as it is so often portrayed. We should set ourselves the challenge.”

We have to see where we stand as regards leadership in the health service and if we have the leadership capability for what needs to be done.

Mr. Kearns said that Hospital Groups and Community Healthcare Organisations would move responsibility, authority and accountability closer to the patient. If we did not achieve that we simply could not deal with the challenges we faced.

An ICT strategy was needed to enable integrated care and in Human Resources a new vision and strategy were needed. We needed ways to design and implement models of care designed not around professional groupings, institutions or organisations but the needs of the people who needed services in a joined up way.