Joint Committee on Health and Children debate -
Thursday, 11 Jun 2015

St. James's Hospital, Dublin: Chairman Designate

Chairman

We resume in public session for our last meeting of the day on the appointment of the chairman designate of St. James's Hospital in Dublin, Mr. Paul Donnelly. As with the last meeting, Deputy Billy Kelleher sends his apologies as he is in the Dáil for Leaders' Questions. I welcome Mr. Donnelly to the meeting and thank him for being here. The committee and I apologise to him for our lateness in starting the session as a result of private business going on longer than anticipated.

I advise the witness that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given. They are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him or her identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

I ask Mr. Donnelly to make his opening remarks.

Mr. Paul Donnelly

I thank the Chairman and members for the invitation to appear before the committee to discuss my appointment. I was pleased to be asked by the Minister for Health, Deputy Leo Varadkar, to become the chairman of St. James's Hospital. Following a request by the joint committee, I welcome the opportunity to introduce myself and set out the main challenges and issues facing the hospital over the next period as well as to outline the future priorities for the organisation. I will summarise the key points in my short presentation. St. James's Hospital holds a unique position in the Irish health system. It is the largest provider of adult acute services nationally and, through a commitment to excellence in clinical care and business processes, it has achieved the position of being, in effect, a national health-care campus. The period of my appointment is a particularly exciting time for the organisation as this position can and should be further enhanced as a result of the major capital investments planned and already taking place on site.

As to myself, I have worked in a variety of roles over the past 25 years, primarily in technology businesses. I graduated from Trinity College Dublin in the late 1980s and spent the first years of my career working for the German engineering firm, Siemens, initially in the UK and then at its headquarters in Munich, Germany. I returned to Ireland in 1996 and joined what was at that time a reasonably small, privately held Irish software business with approximately 40 staff called IONA Technologies.

Over the following four years we grew that business to approximately 1,200 staff, floated on exchanges in Ireland and the USA and achieved a market capitalisation of circa $1 billion. At IONA I was responsible initially for delivering success through forging strategic partnerships and later for the product management of two of IONA's four market offerings. I left IONA in 2000 to form my own start-up and built that business from zero through seed funding and early-stage angel investment and later venture capital funding rounds. On that journey I hired a world-class multidisciplinary team, put the practices and work processes in place for success, mentored and guided the team through the earliest stages and took the business through product launch to closing our first customer revenues.

I have held a variety of roles over my career, including chief executive on more than one occasion. I have served on the boards of a number of commercial and voluntary organisations, including, most recently, two six-year terms from 2002 to 2014 as a member of the board of guardians and directors of the Coombe Women and Infants University Hospital. In that capacity I also served on the quality and risk sub-committee for six years, including two years as chairperson in 2013-14. I am a former member of the executive council of the Irish Software Association, the representative body of Irish software businesses. I am a fellow of the Chartered Institute of Marketing. I am employed by Munich Re, a large German reinsurance business, where I currently act as the executive vice president for Europe, Middle East and Africa of its automation solutions division.

At present I am also a director of Personally Speaking, an Irish-based speaker bureau that provides speakers to corporate events throughout the world, and a director of the Clanwilliam Institute, a centre for systemic therapy and practice in Ireland committed to making psychotherapy services available and accessible to all. Personally Speaking is a commercial organisation while the Clanwilliam Institute is a registered charity.

In some ways I may have gone into more personal detail than committee members were expecting. However, as I move to describe the challenges, opportunities and priorities of the hospital over the next period my hope is that this detail will help give the members of the committee the context to better understand why the Minister may have sought to appoint someone with direct industry experience of guiding an organisation through periods of extreme growth and organisational change, someone who can demonstrate an entrepreneurial attitude to the opportunities such change presents while recognising the value of, and delivering mutual success through, strategic business partnerships, someone who can lead businesses which essentially succeed or fail depending on their ability to attract and retain high-quality top-tier staff as well as someone with specific and significant experience of good hospital governance, including the importance of demonstrable effectiveness of the quality, safety and timeliness of the services delivered and the need for robust financial, corporate and clinical risk management.

With this in mind I will set out what I believe to be the guiding principles of my term as chairman of St. James's Hospital. Fundamentally, I see my role as chairman to be no different to that of every other member of staff in the hospital, that is, to serve our patients and our community. The board of the hospital must ensure that we see the patient or community at the heart of every strategic decision we make. As chairman I will endeavour to build on the success and scale of St. James's Hospital and its many attributes, including its reputation for delivering safe and effective care. A major hospital is in many ways an ecosystem. There are many inter-connections and interdependencies which only become apparent when they are examined in detail. I will not try to fix what is not broken.

St. James's Hospital must continue to attract and retain the best staff. In health the quality of our care is dependent on the quality of our staff. Health care is a people industry and the best are attracted to work with the best. It is a virtuous circle.

I believe strongly in the integration of service delivery, research and education. During my time on the Coombe hospital board I had the great fortune and privilege to serve alongside Dr. James Clinch. He used to frequently refer to the three-legged stool. Through Dr. Clinch's passion I have become convinced that the patients and community benefit directly from there being strength in each leg of the stool.

My background is in one of Ireland's most innovative industries. My colleagues in St. James's Hospital will know that their chairman and board strongly support innovation and change to improve services. Innovation and change must be constant if quality is to be maintained. I will work with the hospital executive leadership to ensure that the culture of the hospital and its partners encourages novel ideas, rewards success and recognises that to succeed an organisation must cherish all attempts at innovation, including those that provide more of a learning opportunity than a success.

While I am clearly excited to take on this position at one of Ireland's health care success stories, the organisation's future still retains a number of challenges as well as opportunities. First, there are significant challenges in providing highly specialist national services while, at the same time, meeting the secondary care needs of an aging and frequently deprived local community.

Second, the new national children's hospital is a critical national project and the successful development and integration of the hospital on the St. James's Hospital campus will be a complex and challenging process. I am mindful and aware of the fact that St. James's Hospital is one of Ireland's clearer success stories of hospital integration and I believe it has the corporate memory to deliver on this vision. Over the span of my career I have become convinced of the key role that information and communications technology investment plays as a key element underpinning successful integration on this scale. A future with adult, children's and maternity care all available on the St. James's Hospital campus offers the unique potential of a care pathway capable of delivering whole-of-life care led from a single campus.

Third, and with more of a focus on opportunity, I will take a moment to discuss scale. Today, St. James's Hospital is already an organisation of scale. With the establishment of the new national children's hospital on campus this will become even more apparent. With such scale comes opportunities to take an all-island shared approach to the provision of highly specialist services, such as the treatment of rare diseases, including rare cancers, where critical mass is key to best outcomes. Such scale provides a platform to strengthen our partnerships with existing partners, such as our academic partner, Trinity College, Dublin, as well as to forge important new partnerships with commercial and philanthropic organisations.

It is important for the committee to understand some context within which this appointment will be made. First, I mentioned earlier that this was an exciting time for the hospital. I wish to draw the committee's attention to the fact that in addition to appointing a new chairman to the hospital board, the hospital is also appointing a new chief executive, Lorcan Birthistle. Mr. Birthistle is a highly experienced acute hospital chief executive with an excellent track record in the leadership and management of complex organisational change. He will take up his post at the end of this month and I am looking forward to a close working relationship with him.

Second, today St. James's Hospital is already an exceptionally well-run hospital. There is a strong senior management team in place with an enviable track record. They are managing an organisation as it delivers safe timely care to a high-quality standard. Along the way they are also acting robustly to mitigate the complex financial, corporate and clinical risks that exist in every health care environment.

St. James's Hospital is fortunate that over the years it has built a well-aligned highly committed team at all levels. Every day, staff at St. James's Hospital display a can-do attitude and look to go the extra mile for the hospital and its patients. I am looking forward to playing my small part in its future. I thank the Chairman and committee members for their attention during my presentation and I am happy to take any questions the committee may have.

Deputy Caoimhghín Ó Caoláin

I welcome Mr. Donnelly and I very much welcome his emphasis midway through his presentation to the effect that he sees his role as no different from every other member of staff in the hospital, that is, to serve the patients and the community. In respect of St James's Hospital, of course, the community is an all-island community. I have had personal direct experience of St. James's Hospital although I am not domiciled within its immediate catchment.

The signalled development of the new national paediatric hospital at St James's Hospital is of course a very exciting project. However, there remains, unfortunately, some body of opinion not reconciled to its selection.

While I am mindful of some of the views expressed, my view, having witnessed the demise of the project to develop the national children's hospital at the Mater hospital, is that we need to proceed with all speed to have the best international standard of care provided for children who will present at the new facility. Members have met the development board, if it can be so described, and I have no doubt we will have a discourse on the project. We join St. James's Hospital in looking forward to its realisation.

Mr. Donnelly did not refer to the signalled intention to have a co-located maternity facility within the footprint of St. James's Hospital. Does he wish to comment on that issue? Co-location is extremely important. A number of the maternity services have been earmarked for relocation or association with other major hospitals in the city.

Mr. Donnelly was previously involved with the board of the Coombe hospital. Will the Coombe hospital be linked to St. James's Hospital? I am not certain if that is the case and perhaps Mr. Donnelly will indicate what knowledge he has in this regard.

Mr. Donnelly correctly described St. James's Hospital as a centre of excellence, which many people, including me, will confirm from personal experience. I wish him well and hope his role in the years ahead will be personally satisfying. I also hope he and his colleagues on the board of the hospital will work together and with all other opinion to ensure the delivery of what will be an exciting national project. I hope, on this occasion, it will be delivered within the scheduled timeframe.

Deputy Seamus Healy

I welcome Mr. Donnelly and thank him for his presentation. His curriculum vitae is highly impressive and indicates he has been involved in health matters for approximately 12 years. He has been involved in the Coombe hospital and appears to have garnered the expertise required to assume the role of chair of St. James's Hospital. I have a global question for him. What does he envisage will be the role of St. James's Hospital at the end of his first term as chair?

Senator John Crown

I apologise for missing the beginning of Mr. Donnelly's presentation. I wish him the very best in his new role. My first oncology job was in St. James's Hospital many years ago and I have a large well of warm and sentimental good feeling about the institution. It is, in the Irish context, a wonderful hospital. While things in Ireland are not great by international standards, the hospital certainly punches above its weight and is a great place.

Mr. Donnelly has left a world of fairly rational and understandable forces in international business and is about to engage in a world in which the forces are less rational and the consequences of actions less predictable. Moreover, there are not necessarily positive incentives in place for good behaviours on the part of the hospital. For example, if it does things right and increases efficiency, it may well find itself having its funding reduced.

I hope that, as he steps forward into this job, Mr. Donnelly will turn his thoughts to an issue which has been close to my heart for 22 years and about which I am increasingly despondent. I refer to the need for fundamental reform of the health system. While I do not intend to personalise this issue, I work in an institution in which the board structure has not worked well. We have seen considerable evidence of this recently. The true stakeholders in the system need to become engaged again with the people who choose and run the board of an institution. Having an absentee landlord mode for hospital boards, such as that in place in many hospitals where people no longer involved in the running of the hospital choose the entire board, is not a rational system. The model in place in St. James's Hospital has worked better.

It is my dream that St. James's Hospital will some day be taken over lock, stock and barrel by Trinity College to become the TCD medical centre. We have never got our heads around this type of model, which works extraordinarily well for major academic medical centres around the world. I once hoped that at one stage my medical school, University College Dublin, would take a similar view towards its two large constituent hospitals, the Mater hospital and St. Vincent's Hospital, by, as it were, liberating these hospitals from their current ownership and redirecting them to become the types of leading academic centres they should become. We are not good at this in the health system.

I once stated, only half-sarcastically, that one sometimes gets the impression that the people who planned the Irish health system studied all the other international models of success and decided to do exactly the opposite. If Mr. Donnelly has not done so already, I suggest he examine the five or ten largest and most successful medical systems in the world to see how their board structures work. The place in which I was most involved in the United States, Memorial Sloan Kettering Cancer Center, was an entirely private, not-for-profit institution which was based on an ideal, namely, to cure cancer. People served on the board for this reason and because they wanted to be part of the war on cancer. In some cases, their lives had been touched by cancer, while in others they were co-opted because they brought expertise. Many great donors were also appointed to the board. It is necessary to examine alternative board models. I would be interested in having a chat with Mr. Donnelly in a year's time to discuss his experience in the intervening period.

Mr. Donnelly failed to mention that St. James's Hospital has been an ambitious institution which has sought to become bigger and better. It aggressively campaigned to become the designated location for the national children's hospital and was ultimately successful in this regard. I admire and respect it for that. My position in the debate on the location of the national children's hospital continues to be that it was nearly impossible to obtain a medical opinion on the location of the hospital that was not, in some sense, biased by institutional loyalty on the part of the person making the statement. I do not propose to debate the issue again.

At the time, I argued that we should all support locating the hospital at one site and that once a site had been chosen, we should all shut up and get on with it. This is exactly the point we have reached with the national children's hospital. The debates are over and it is time to get on with building the darn thing, rather than condemning children to additional years of substandard accommodation when their care is being delivered.

This is not a loaded question but is being the chairman of the board of an institution such as St. James's Hospital a full-time job or will Mr. Donnelly pursue other jobs at the same time? Is it a full-time vocation? I do not understand how this works.

Senator Colm Burke

I thank Mr. Donnelly for his detailed submission. His curriculum vitae is highly impressive. I congratulate him on his achievements to date and wish him well in his new role.

I will raise two issues of great relevance to the health service. Mr. Donnelly has acquired considerable experience in technology, an area in which health service has not been heavily involved. I understand, for example, that 1,700 computer systems are in operation in the health service. Since 1994 or thereabouts, the Danish health system has been trying to consolidate its information technology systems and has reduced the number it operates to 20, with a view to further reducing it to five. In fairness to St. James's Hospital, it is reasonably advanced in terms of information technology. Will St. James's Hospital be able to work with the Health Service Executive to try to provide a single system for the entire health service?

It would provide efficiencies across the board.

A major issue that we are addressing is that of litigation involving hospitals. In a number of presentations made to the committee, there was a great deal of criticism about how claims were dealt with once they were lodged. How will this situation in the medical profession change in the coming years? This is a question of taking responsibility earlier than on the steps of the courthouse. Regardless of how good a service St. James's Hospital provides, mistakes will be made and there will be claims. That is the real world, but despite the fact that our approach to them has not changed in the past 25 or 30 years, the level of claims continues to increase.

These two issues are important and we need major changes in respect of them in the next five years.

Deputy Catherine Byrne

I am delighted to meet Mr. Donnelly and welcome him to this meeting. I was going to welcome him to Dublin 8 but I do not need to do that because, as we all know, he has been involved with the Coombe hospital for a long time.

Mr. Donnelly is going to the St. James's Hospital's campus at an exciting and challenging time. As someone who does not live far from it, I have always been intrigued by the comings and goings of the people there and the talents that they have brought. There is no end of talent in the CV that Mr. Donnelly mentioned. I stated "challenging time" because, as a local public representative, I can hear the rumblings in the camps about the new national children's hospital. We should be standing on every rooftop and singing about how wonderful it is to have the national children's hospital in the Dublin 8 area. It will not only enhance the campus, but also the wider community. In the long term, local people will be able to work there, as many already do at St. James's Hospital. I hope that Mr. Donnelly, as chairman of the board, will be able to enthuse and get as much information out there about the new hospital as is possible.

We are coming to a tricky time. I listened with great interest when Senator Crown stated that we finally had a site and needed to get behind it to get the job done. However, there are rumblings on the ground among residents. We understand their concerns, which I hope can be dealt with carefully. It is important for the complex's future, and particularly that of the national children's hospital, that there is someone like Mr. Donnelly within the campus who has a wide range of experience, including in business.

I hope that we will not have to climb every mountain to get the children's hospital over the line when it enters the planning process in July. It is an opportunity to have expertise and state-of-the-art facilities and to avoid shifting children who are ill from one end of the country to another. I am looking forward to it. This committee visited the site. Anyone to whom I have spoken about the new hospital or St. James's Hospital, including my family, had nothing but the height of praise for both.

I wish Mr. Donnelly the best and hope that our paths will cross again, if not at committee level, then in our efforts over the coming year to get the hospital completed.

Chairman

As there are no further questions, I invite Mr. Donnelly to respond.

Mr. Paul Donnelly

I will try to address the questions largely in the order that members put them, but I will take one out of sequence, that is, Senator Crown's. He asked about how much of a full-time job this role was. That puts a context on my answers to all of the other questions, so I might take it first, if the Chairman does not mind. This role is an unpaid, non-executive position. It is far from a full-time role within the health service. I have explored it and discussed it with my family. I have the capacity and the time to deliver a non-executive commitment to the organisation.

Deputy Healy had what I hope was a slip of the tongue when he asked about-----

Deputy Seamus Healy

Possibly.

Mr. Paul Donnelly

-----what I planned to do in my "first term". He cannot say that in front of my partner. He would create great domestic difficulty. I can commit as a non-executive for one term and we will examine it later. With that context set, I will go through the points.

When Deputy Ó Caoláin discussed selection, I take it that he meant location selection.

Deputy Caoimhghín Ó Caoláin

The site, yes.

Mr. Paul Donnelly

There have been many discussions on the matter. To step back for a moment, my background is in the software industry. One can spend a great deal of time building software products and getting everything perfectly right, but by the time one has done that, whatever market one sought to address has gone. I echo the comments of Deputy Ó Caoláin, Senator Crown and Deputy Byrne in that we must shut up, get going - all of the terms that were used today - and move on with it. There comes a time after we have made a choice to do that. We cannot procrastinate.

Deputy Ó Caoláin asked about maternity services. A maternity services review is under way. To my knowledge, and I hope that I am not paraphrasing inappropriately or incorrectly, there is an assumption that some form of maternity services will move to or be established on the St. James's Hospital campus. I believe that the review is considering what form that will take. I do not want to prejudge it. On the assumption that there will be maternity services on site in some form, it will provide us a unique opportunity to have a whole-of-life model of care and care pathway for our patients. This provides interesting and major opportunities in terms of service delivery as well as education and research, for example, long-lived studies that are led from one campus and that our patients go through to various stages in their lives.

There is a link between the Coombe hospital and St. James's Hospital in that they share consultant posts. It is through feet on the ground and other such bonds that the organisations are brought together. It is great that the boards can talk and have a good relationship but it is when there are shared consultant posts, people working in both organisations and patients transferring from one to the other, which is a common practice, that linkages are really established.

Moving on from the referenced "first term" to where I see the situation at the end of the term, I would love to have successfully established and integrated the children's hospital. Senator Crown referred to the organisation's ambition. It might be overly ambitious to say, "to have successfully embedded maternity services also", without leaving a hostage to fortune. I am allowed to have an ambitious vision. I am also allowed to not achieve it all. I would like to see both of these projects established. They give scale. There are a great deal of secondary benefits, for example, opportunities to establish linkages with philanthropic and commercial organisations that could be of great benefit to the patients and community and that, on a global scale, do not have the resources and cycles to deal with small local organisations but can support larger ones.

It gives us an opportunity to form a different scale of partnership which would be quite useful.

Senator Crown raised several questions around the philosophy of board structure and the rationality of the organisation versus my position. I am not leaving the rational world as he would describe it. I hope to form a bridge between his version of the rational world and the irrational. I know from the 12 years with the Coombe hospital that they are slightly different worlds and that there are differences between the two. There are also commonalities between the two. In particular, through the presence of board members with commercial experience and ongoing commercial experience not just in St. James's Hospital and the Coombe hospital but in other organisations, the opportunity to bring ideas from one world, as Senator Crown would say, to the other is growing and getting stronger. Senator Crown referred to his personal experience in the United States working in successful academic medical centres. There are already several group linkages of which St. James’s Hospital is a key member. One is Trinity Health Ireland which encompasses the academic teaching hospitals associated with Trinity College, Dublin, namely, St. James’s Hospital, the Coombe hospital and Tallaght hospital. There is also the wider group which is the Dublin Midlands Hospitals Group which encompasses those organisations together with Tullamore, Laois and Naas hospitals. These are new groupages which are finding their feet. It is not a bad time to have this philosophical debate but maybe not at the St. James’s Hospital board level but at the group level.

To address Senator Colm Burke’s questions, I am acutely aware of the systems situation. There are positives and negatives to having one unified system. If one builds everything into one unit, it becomes hard to effect change and move it. I concur with the Senator that the health service needs to get a grip on its use of modern technology. Some work is already happening around that. I am encouraged there is a central enterprise resource planning system in St. James’s Hospital which is the same calibre of software which is used in most substantial organisations in Ireland and worldwide. I am in the fortunate position to be entering a role in an organisation which is better prepared than many of the organisations to which he referred.

He also raised the valid point about the ability of the broader health service to deal with mistakes. There were some good quotes in today’s newspapers from a family who suffered a similar journey to what he described. The father made some spot-on comments. Mistakes happen everywhere in the world but when they happen in the health care system, they have grave consequences potentially for patients and their families. There is some understanding that mistakes potentially happen. The process that happens afterwards can be the most dispiriting for those who have suffered as a result of an error or an unfortunate happenstance. I would welcome a review of how we deal with that in the health service. It is unfortunate that we have a liability-mitigation culture in many ways. Many of the clinicians who display those tendencies, unfortunately do so on management and legal advice. It would be great to have a system where there could be more transparency without exposing the organisation to potential liabilities. Unfortunately, in my small part of the world, I am not sure I will be able to single-handedly address this. However, these are well-placed sentiments which I support entirely.

I hope Deputy Catherine Byrne does not mind me describing her comments as a reflection of local rumblings. As she correctly pointed out, there is a division between positives and negatives felt there. To be honest, it is a division between the perception of potential positives and potential negatives. When there is change on any scale, there is always a little bit of apprehension. This is an issue for us all as individuals. It becomes more amplified in groups. If we have a common concern and we talk about it, it becomes a bigger issue. Over the course of this development, as things become more concrete and more real, the people’s apprehensions, and perhaps unfortunately their optimism about the upside, come closer to the centre. As I said to Senator Colm Burke about the claims liability issue, I probably cannot do an awful lot about that. However, in this very specific case, I can do a lot about it. What I can do is encourage the organisation to be transparent and open. As we are transparent and open, we give a better understanding of what the opportunities will be for the local community and what impacts there are going to be. Inevitably, there are going to be impacts. As we take a national institution into our community, we have great sense of pride about that. The pride is also centred around the fact we are doing our bit for the nation. There will be a sense of that in the community. The one thing I can do is to encourage the institution to be open and transparent.

Chairman

I thank Mr. Paul Donnelly sincerely for his presentation and his informative question and answer session. I thank members for their time this morning. It is proposed to send a transcript of the meeting to the Minister for Health for his information.

The joint committee adjourned at 1.10 p.m. until 9.30 a.m. on Thursday, 18 June 2015.