Autonomy and governance at risk

The initial signs that the future hospital trusts will be independent were not encouraging and evidence suggested that what was proposed would destroy that very autonomy and governance and the quality of patient care that was associated with the voluntary sector, Dr. Ruth Barrington told the Voluntary Healthcare Forum in the Royal College of Physicians.   Maureen Browne reports.

Dr. Ruth Barrington
Dr. Ruth Barrington

Dr. Barrington said that without debate or rigorous analysis, the development of policy on the creation of hospital groups had changed from a proposal to resolve the future ownership of HSE hospitals to one that was radically reorganising all statutory and not for profit hospitals in the state.

“It suggests to me that what is proposed is not so much a divestment of HSE/Department of Health responsibility for the hospitals in public ownership as – and I choose my words carefully – an effective nationalisation of hospitals that are independently owned and/or governed in the proposed trusts”, Dr. Barrington told the Forum.

However, she said she did not think it was in the state’s power to ‘devolve’ autonomy from voluntary hospitals to the new hospital groups.

She did not think it was in the state’s power to ‘devolve’ autonomy from voluntary hospitals to the new hospital groups.

Dr. Barrington said it appeared that the original intention of the Government was to provide an independent governance structure for former HSE hospitals and to encourage the smaller of those hospitals to combine in hospital networks. There was no reference to hospital groups at all. There was no mention of the inclusion of voluntary hospitals or of the hospitals with statutory boards, such as St James’s Hospital or Beaumont Hospital.

But, by the time of the publication of Future Health –A Strategic Framework for Reform of the Health Service 2012-2015 in November 2012, thinking had changed. The ‘public hospitals’ referred to were no longer the HSE hospitals of the Programme for Government, but was then being used as the generic term to include HSE and other statutory hospitals on the one hand and voluntary hospitals on the other and all were to be organised into hospital groups.

Turning to centralisation and governance, Dr. Barrington said that while the Government promised the abolition of the centralised HSE, so far all we had seen was the abolition of the board of the HSE. The Director General of the HSE now reported directly to the Secretary General of the Department of Health. “What was once a clear division of roles in the health service between that of the Department in respect of finance, legislation and national policy and that of the health boards and then the HSE to deliver health services, has been blurred if not entirely removed. At the same time, the control of public funds voted for the health services is returning from the HSE to the Department of Health. The Minister and the Department have now highly centralised control of the health system and everything points to an increasing level of control rather than to any devolution.

This is most peculiar governance, as anyone who has every managed an organisation or been on the board of an organisation, even a public organisation, will know.

“The chairs of the new trusts have been appointed by the Minister for Health and it appears that the Minister will appoint members of the boards of the independent trusts, According to the Higgins Report, the CEOs of the hospital groups report to the Director of the HSE/Director of Hospital Services or equivalent – not to the chairs and the boards of the hospital groups that employ them.

“Even when the proposed ‘independent’ trusts are established by legislation, the Higgins report recommends that the CEO of each reports through his or her chair to the Director of the HSE/Director of Hospital services or equivalent. This is most peculiar governance, as anyone who has every managed an organisation or been on the board of an organisation, even a public organisation, will know.”

“Combine ministerial control of board membership in an Irish context with an overwhelming dependence on public funding – either under the current budget allocations or the proposed ‘money follows the patient’ model and for capital developments – and add the requirement of compliance with policies on procurement, payroll and recruitment and you have state owned and managed public organisations in all but name.”

Dr. Barrington said that in the absence of evidence that the Department understood the essential elements of good governance for hospitals and the relentless concentration of more control of the health system in the Minister and Department of Health, one would have grave fears that the current robust governance of the voluntary hospitals would be run into the ground and, indirectly, the care of patients put at risk.

“My most serious criticism of Future Health, the Higgins report and the White Paper on UHI is that they do not address the issue of legal status and ownership of voluntary hospitals in the context of a hospital group or future trust. One would have expected some acknowledgement of the legal basis upon which voluntary hospitals were established – by Royal Charter, under Acts of Parliament, as limited companies with charitable status, or Public Juridic Persons – and the fiduciary duties of the guardians, governors or directors arsing from their legal obligations. But no, they are treated as ‘public hospitals’ in the same category as the HSE hospitals that have no tradition of independent governance.

“I am not a lawyer but it seems to me that any suggestion that a legally appointed board of a hospital voluntarily hands over its responsibilities for governance of its hospital to an un-established, interim group of people, no matter how well intentioned, would put the board of that hospital in serious breach of its legal responsibilities. There are similar problems with any suggestion that the management team of a voluntary hospital bypass its board and report to a group management structure – particularly during this ‘administrative’ phase of the existence of hospital groups.”

Dr. Ruth Barrington is a Trustee of Genio, former Chief Executive of Molecular Medicine Ireland, former Chief Executive of the Health Research Board and former Assistant Secretary of the Department of Health and Children.