The Title of the Bill is the Health Service Executive (Governance) Bill but it should really be titled the Health Service Executive (partial governance) Bill because it deals predominantly with new directorates rather than a reform of a whole governance approach to the HSE.
The big myth about the HSE when it was established was that it would replace the old health board system. In fact, what occurred was that public representatives were removed from the boards and a new administrative tier was placed above what was a dysfunctional health board system, which was really a product of the 19th century poor law system. The top-down system remained in place but there was a need for the whole organisation to be reformed. Despite good people working in it, the structure and culture ended up being a failure. It is beyond question that there were abuses by public representatives on the boards. While I do not stand over that, they did, however, perform an oversight role which was lost when they were removed and that has never been properly replaced.
The HSE, instead of simplifying things, introduced a new level of bureaucracy that has proven to be extremely difficult to interact with for the citizen, which feeds into clientelism. An organisation cannot have a clientelist approach unless its systems of governance are inaccessible to the public, meaning that people have to go through a middle man or woman. That is one of the dysfunctional things about Irish politics.
A good citizen interface for any organisation is essential in any reform process and this must be underpinned by the services being available. A website is now the shop window for any service and I challenge anyone to make sense of the HSE's website. A website is a mirror image of the organisation it represents. The processes, culture and services can all be seen and to me it looks like chaos. It looks like an organisation that is inwardly focused and process driven. It is a tall order to expect that the changes proposed in this legislation, namely to replace the board with a new directorate, can deliver the kind of change that is needed. This was the approach that was taken with local government, where directors of service were introduced but it did not change the culture because what was underpinning it was not changed. Much more substantial reform is required. I accept that this might be done on an incremental basis but we need to see what is the overall blueprint. The people who work within the system and the citizens have a right to expect that.
The HSE was also a very useful vehicle for Ministers in the past in terms of blaming the organisation rather than accepting responsibility for failings. The HSE served as a kind of teflon for the Minister for Health. Parliamentary questions often took a ridiculously long time to answer and there is still a difficulty with accountability. Responses from the HSE take longer than other parliamentary replies. Another difficulty is that several Deputies are often asking the same question of the HSE. There is duplication by virtue of the fact that one has to look in another location to determine what questions have been asked previously by others. There is room for efficiency in this area, in terms of improving accountability and taking a simpler approach to finding out what is happening.
The provisions of this Bill are intended to change all that but it will require a change in both structure and the organisational culture to achieve this. The existing accountability arrangements under the Health Act 2004 are retained and they relate to service plans and annual reports but in many cases these are deficient. There is no point in having service plans if there are no services available and I wish to cite a number of examples in this regard. People often criticise politicians for spending time in their constituencies once or twice a week and accuse us of fixing potholes. I wish it was only potholes that we were attending to but the issues are much more complex. Deputies can see the failures in the system. I was approached by a family with a 12 year old child who was ready to begin secondary school. She has been on the waiting list for a tonsillectomy for the last two and a half years. She is missing school regularly and on antibiotics frequently, which is not the kind of case management one would want. She is not well and is losing weight. She has been waiting for an appointment in Tallaght hospital for over two years and her parents have no private health insurance. They asked if she could be moved to the waiting list for another hospital because if she was on the list for the actual procedure, rather than for just an appointment, she might be able to get treatment under the National Treatment Purchase Fund. This is the reply her parents received from Crumlin hospital: "Thank you for your referral to the ENT department. Currently the outpatient waiting time is two years for a routine ENT appointment". The hospital refused her referral. We are busy talking about building a children's hospital, which is desperately needed, but while we are waiting for that, we are seeing the failures. That child is being failed. There is no point in having service plans unless there are services behind them. We need real reform that will impact on people.
Access to services can often depend on one's address, which is a lottery I frequently come across. In many cases, this affects children who need essential services such as occupational therapy. Again, I have one of many examples of this. The HSE informed me that the paediatric occupational therapy service was developed in Kildare, west Wicklow in 2009. It added that the resources have been depleted in recent years due to resignations and it has not been possible to replace the staff due to the moratorium on recruitment. This is penny rich and pound foolish because, in many cases, children will miss out on the developmental opportunities provided by occupational therapy and we will pick up the tab later by way of disability payments and so forth. This is stupid. Service availability is very much dependent on where one is in the country and for children living in a different part of the country, this is not a problem. I do not see how a new directorship will make a difference in this regard. Will people be moved from Cork to Louth or from Galway to Kildare? We need a whole-of-organisation approach to understand where people are, where the gaps are and how we can plug those gaps.
I have another example of an eight year old who is falling through the cracks. He struggles to dress himself, cannot hold a knife and fork and needs occupational therapy but he cannot even be put on the list. He was diagnosed by the Child and Adolescent Mental Health Service, CAMHS, with Asperger's syndrome and attention deficit disorder but his parents were told that he would not be seen because there was no list for him to be put on. The CAMHS does not have an occupational therapist, even if he was to be referred back to it and community treatment is not an option any longer. This may well be a local play-out of this problem but it is impacting negatively on the child. A new directorship and service plans will not resolve this issue if the people are not in place and I cannot emphasise this strongly enough.
I have another example of a child who has a specific learning and language difficulty. Speech and language therapy will not be provided in the school in Tallaght that specialises in treating the small number of children who have this disorder. He is emotionally impacted by this but is also impacted badly in terms of his educational prospects. When the particular service is provided, a child is taken out and given intensive occupational therapy for two years and then returns to mainstream school. The experience of children who have gone through that route is very good. In my view not having those services in place is criminal. I have come across several children who need behavioural therapies. I have had parents tell me that their big fear is that if their children do not receive the necessary treatment, they will end up in prison. They are displaying violent tendencies at primary school. They clearly have some difficulties and need behavioural therapies to modify their behaviour. Their parents have said to me, bluntly that their child will end up in prison. We talk about the past, about failures and the kind of Ireland we used to live in but this is the Ireland of now. These are people I am coming across regularly and I do not suppose that Kildare is different to other parts of the country. It may well be that there is a more deficient service in my area by virtue of the fact that the population increased rapidly in a very short space of time and the services did not keep pace with that. We are now struggling with that and people are being lost in the system.
Another issue of major concern, which is not being provided for, is the fact that we have younger cohort of people working in our public services. Older people have tended to be the ones who have opted out when retirement packages were put in place. Approximately 50% of these younger people are women as more women need to work these days because of large mortgages and so forth but no cover is being given for maternity leave.
We cannot be serious about providing a service unless we cover something like maternity leave, as that is where gaps occur. The coverage of maternity leave is essential.
A huge number of good people are employed in the HSE and most of the workers are not responsible for the structure of the organisation. I am sure these people are frustrated by the service within which they work but any change must occur with their co-operation. I am concerned about the top-down approach. We are told new directors will have a critical role to play and I hope that ends up as the case. It is not just a question of hiring good people to fill those directorates, and the process must be underpinned by values and objectives.
As an example, the robotic approach to the home help system in recent months flies in the face of the objective of trying to keep people living independently within their own homes for as long as possible. It cannot purely be about financial outcomes and I am concerned about the market and management language being used. People who use the health services are not customers but they are citizens who pay their taxes if they are lucky enough to be able to do so. They have an entitlement to a service when it is required. We should stop the management speak. A 12-year-old waiting for an emergency medical procedure is not a customer but a citizen of the country who is entitled to be cared for. Citizens must be put at the heart of redesigning the process, as the outcomes are for these people.
Nevertheless, it is essential that we get best value from the limited funds available and it is clear from the leaked reports in recent years that internal audits are extremely lax when it comes to oversight of spending by the HSE. This is unacceptable and it must change because we cannot afford waste. What is proposed is limited and there is a need to see the shape of the organisation that will run our health services. This piecemeal approach is not convincing.
There was a very useful paper delivered some years ago at the MacGill summer school, with Mr. Eddie Molloy talking about Ireland's sixth crisis involving a severe implementation of deficit disorder. For those of us who want to see significant or radical reform in many of our institutions, we can identify with the idea. Mr. Molloy indicates that the main carriers of the disorder are organised groups with strong bargaining power. He includes in this senior public servants, executives, medical consultants and board members who have reached the top of their respective organisations. They are a good cultural fit for the board and unlikely to question the prevailing culture, amounting to a safe pair of hands, with a core value of loyalty to a group or circle, golden or otherwise.
Mr. Molloy argues that we need to strengthen the strategic centre and that we need to establish the discipline of real, edgy, transparent strategic management. Public agencies publish strategic plans approximately every three years but the track record in implementation is poor; we know this because they are all on shelves. Mr. Molloy argues that there is a belief that a job is done once a report is published and people can read it but there is no effective system of strategic review and transparent reporting. He also seeks the formation of senior public servants, which means they should not merely be trained in administrative and sector-specific skills and there should be inculcation of a value system. He identifies institutional culture as the root cause of failure and the biggest obstacle to reform, highlighting several concrete steps that can be taken, including boards and senior executive teams giving quality time on a regular basis to engaging with an organisation's values and culture. A cultural audit must be an integral element of strategic planning, with a section of culture a requirement in all annual reports.
Culture can be very difficult to change in an organisation but if it is not on the agenda, there is no chance of changing it. Mr. Molloy also speaks about initiating a major multi-year programme to reappropriate and breathe life into the foundational values of the public service. We must be deliberate in the kind of change being sought. These are elements in a longer paper that has a wider scope but it is nonetheless relevant to this proposal.
We have an old poor law model that we are trying to tweak, which is not good enough. What is beneath the directorships requires radical reform. The structure and culture of the executive are in need of reform, with a whole-of-organisation reform required. The top-down model was an intended change in the HSE and we can see that it did not work. I do not understand why it continues to be the favoured approach when a whole-of-organisation approach is required. It does not matter how good this organisational vehicle becomes if we do not have people with the right skills in the right places to deliver services to the public. It does not matter how good the management system is in that case and there are serious deficiencies that will cost both money and opportunities. These must be addressed and to give the impression that this is a big reform, with addressing such issues, will be seen as a failure for people who present with the kind of examples I used. I wish these were the only examples I could use but unfortunately every one of us has a group of people seeing deficiencies in service delivery. I am able to put my hands on just a few in order to give an example.
I am not opposed to the Bill but it is very limited in what is being done. We need to see urgently what will be the overall shape of the HSE in future.
