Mr. Leo Kearns:

This is why we are putting such a huge focus on what we call the control model. How does it work? We said that one of the key things, in addition to appointing the leadership teams for the RHAs, is that there is significant work to be done on the organisational structures within the areas and that has to go down to patient level. A key part of that is all the authority that RHAs need to fulfil their responsibilities has to sit at the RHA level. However, the RHAs then need to understand that they must devolve some responsibility and authority further down because, with the best will in the world, whoever leads the RHA is not on the ground in Clifden District Hospital.

A big challenge for RHAs is how to create that sense of ownership and empowerment right down at patient level, which means that one must allow some decisions to be made on the front line, within the community and so on. The big part of that is one needs to have that clarified upfront. So when one designs the RHA, one must say these are the decisions that need to be made at the regional level and these are the decisions that are made at a local level. When a decision is made, it is not like someone can go off and just make whatever decision he or she likes. He or she must be accountable for the decisions made. He or she cannot create a situation where someone says he or she is managing the hospital yet cannot make a decision, which should be his or her decision to make, because he or she has to get approval from two or three levels above. That would be authority in name only and is a terrible place to be. We are saying that a big piece of work to be done by the RHA is figuring out the organisational design within the area, which is just as important as how the RHA relates to the centre, for instance. We do not want to create a sense that in the RHAs there is some kind of command and control centralised function. That just does not work in a complex system. It cannot work. There must be collaboration, good planning, clarity on who is responsible for what, and if someone is made responsible for "X" then he or she needs to have all of the authority that one needs to deliver "X". As we now know, most of these authorities now sit at the centre rather than with the hospital CO even as we speak. That is a critical element in all of this.