Oireachtas Joint and Select Committees
Wednesday, 3 July 2019
Joint Oireachtas Committee on Health
Health Service Executive: Chairman
The purpose of this morning's meeting is to engage with Mr. Ciarán Devane, the new chairman of the Health Service Executive. On behalf of the committee I welcome Mr. Devane to the meeting and congratulate him on his appointment. I wish him the best of luck. We have great expectations of the new board. Mr. Devane will outline his experience and strategic vision for his new role, particularly in light of the challenges we face in the implementation of Sláintecare. I note that the new board of the HSE held its first meeting last Friday.
By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a 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 and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. I also advise the witnesses that any opening statements they make to the committee will be published on the committee's website after this meeting.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.
I call Mr. Devane to make his opening statement.
Mr. Ciarán Devane:
I thank the Chairman and committee members for the invitation to attend today in my first full week as the chairperson of the new board of the Health Service Executive, HSE. I am joined by Mr. Jim O’Sullivan, who has been appointed as secretary to the board.
The Minister for Health signed the commencement order for the Health Service Executive (Governance) Act 2019 last week and attended the first meeting of the new board on Friday. The establishment of an independent board to oversee the HSE is a really important step in improving the governance of the health service. It is also one of the key recommendations of the Sláintecare report, which is the first of two reasons I am privileged to be here today. I and my fellow board members will make as good a contribution as we possibly can to achieve the committee’s expectations as expressed in the report. As one reads the Sláintecare report, one gets more and more excited and impressed. The plan and the cross-party support for it was a large part of why I went for the role.
The committee’s invitation referred to gaining an insight into my experience and vision for the role on this, the most important State board. I was educated, as Gaeilge, in Coláiste Mhuire in Parnell Square, Dublin, and as a chemical engineer at UCD. My work experience to date has largely been in the UK with some time in the US and continental Europe. My early career was in the chemical and life sciences industry, followed by time in management consulting where most of what I did was run complex change programmes in large multinational companies. I have been chief executive of the British Council since 2015. I have focused on aligning the British Council behind key themes important to the UK in education and culture, as well as strengthening the organisation’s capacity and capability across its network of offices in 115 countries.
It is probably the bit in the middle which is more obviously aligned with the HSE. From 2007, I was chief executive of Macmillan Cancer Support where I helped the organisation reshape cancer services across the four nations of the UK, both on its own and in collaboration with other organisations, leading to Macmillan being perceived consistently as the public’s most respected charity in the UK. Some of what we did was about new care models, the use of data to measure and improve outcomes, while other aspects were around focusing on patient experience.
In terms of governance, I have held non-executive roles on the boards of a range of organisations from small local charities to the board of NHS England, which commissions healthcare for the population of England. There are differences, as well as similarities, between the HSE and NHS England. Both, however, are the organisations and boards with the ultimate accountability for spending taxpayers’ money to deliver the best possible healthcare for the available money for the population of the jurisdiction.
I believe my experience to date puts me in a good position to lead the board of the HSE on its transformational journey as set out in Sláintecare, while holding the HSE to account for delivering the current plan. In doing so, we must have the credibility to make the changes needed to have a health service that will continue to serve the public into the future.
The board had its first formal meeting on Friday, but we had got together informally several times previously. I am pleased with the calibre of those the Minister has appointed to the board of the HSE. Like myself, and indeed all those who believe in public service and the public health service, we are united in having a driving ambition to ensure Ireland has a world-class health system of which we can be proud. The board currently comprises ten other members, with an additional member to be appointed by the Minister presently. We are varied and have different competencies, including clinical and governance expertise, patient advocacy, change management and financial management. My role is to bring this together into one properly functioning board, holding people to account while, at the same time, driving strategic direction. I am pleased with the appointment of Mr. Paul Reid as chief executive officer. I look forward to working with him and his executive colleagues on this shared ambition.
The cross-party political support that underpinned the development of Sláintecare gives us a great and once-in-a-generation opportunity to build a forward-looking health service. The board must exploit the momentum for change in the best possible way. We must ensure we have the right systems and controls in place to ensure the financial stability and predictability of the HSE. The board must support the executive to ensure we create public confidence in the HSE’s financial management, which will then allow us to seek further investment for the implementation of other aspects of Sláintecare.
I have had a chance to discuss our short-term and long-term priorities with board members, officials and Ministers. The key priorities are developing and implementing an effective performance management and accountability system in the HSE; building public trust and confidence in the HSE and the wider health service; ensuring the HSE’s full support for and implementation of the Government’s programme of healthcare reform, as set out in the Sláintecare implementation plan; and supporting the leadership and staff of the HSE to continue to improve health outcomes of the public, as well as retaining them.
There is a great deal to be proud of in our health services, in particular the significant progress made on outcomes such as increased life expectancy. Since 1990, life expectancy in Ireland has increased by almost seven years. In an average year, the life expectancy of our population typically goes up three months. In a typical day, it goes up six hours. On average, since 1990, every day of every year has seen life expectancy of the average citizen go up by three months per year. This is truly astonishing and one of the fastest rates of improvement in developed economies. There is more to be done, however.
On behalf of the board, we are looking forward to working with the wide range of stakeholders, including the committee, to do the job recommended in Sláintecare, which is expected of us.
We will do our very best Chairman, as always.
I thank Mr. Devane and Mr. O’Sullivan for appearing before the committee and wish them the best of luck. The HSE is one of the most, if not the most, important and complex organisations in the country. Having the board back in place is certainly good and welcome, as the abolition of the board some years back was a serious mistake. The health system has certainly suffered without having a board in place.
One of the three main roles of any corporate board, particularly of an organisation of the scale and complexity of the HSE, is the development of strategy.
The second role is accountability of the executive team, in terms of holding it to account, putting sanctions in place or removing them when necessary, or rewarding the team through remuneration and so on. What is the witness's understanding of this board because arguably it is a bit different? Does he believe it has a role in setting strategy? Presumably he believes holding the executive team to account is one of its roles, but does he believe its powers extend to tabling sanctions if necessary, up to and including removing the director general or other members of the executive team? On the flip side, does he any powers or authority in granting whatever rewards might be deemed appropriate by the board, at a director general or executive team level?
Mr. Ciarán Devane:
I believe we have a role in determining strategy, in collaboration with others. We operate in an ecosystem. The policy side of strategy, which is the purview of the Department, informs how we do what do. That needs to be a dialogue, and there are choices to be made in finding the best way to implement an agreed overarching vision and strategy. If strategy is about making choices about what to do when, what to do later, and what not to do at all, then we absolutely have to have a role in that. However, I do not believe we should do that in isolation. It is a public sector board, so we do it in the context of overall policy, and we have to ensure we work with the other organisations in the ecosystem as well. We should not be isolationist or do things on our own. We have to engage in that dialogue. If we believe that good dialogue leads to good strategy, then that is important.
In terms of accountability, as well as having the carrot and the stick, it is important to have the right processes in place, because they create clarity so people know what they are being held accountable for, and that that accountability is for the whole range of things. One person is not accountable for the money and someone else for meeting the access targets. It has to be collective because they are so intertwined. I see it as making sure that cascade of accountability, and the necessary clarity, are in place. We also need to recognise and reward where people are performing. The reward does not have to be financial, but can be about opportunity, engagement, promotion, and so on. Equally, if someone is not performing, we need to have a conversation with them, and they might be better off elsewhere.
I will ask my other questions in one go, because we are stretched for time. I note that in Mr. Devane's opening statement, he refers to the board's priorities. Those priorities are all fine, but I do not see issues around access for patients or quality listed there. People are now waiting three, four, or five years just to see a consultant. Access in some areas in Ireland is worse than in parts of Africa. It is the worst in the OECD, and we have the lowest number of consultantsper capita anywhere in the OECD. We have the second lowest number of hospital beds in the OECD. We have reached a complete crisis. Consultants say the hospital system is on fire. There is a crisis in the lack of access for men, women, and children. The narrative is that the Irish healthcare system is difficult to get access to but is brilliant once one gets in, but while bits of it are, other bits are not. We have unsafe staffing levels all over the system, which was noted in Mr. Paul Reid's briefing. As the incoming chair, what are Mr. Devane's views on this? First, would he agree that we have a crisis in access to healthcare? What needs to be done in the short term to deal with these waiting times of three, four, or five years? What are some of his short-term priorities for the board, in order to address some of the quality issues in the system, while accepting that some of it is excellent? I will leave my questions at that.
Mr. Ciarán Devane:
That is obviously a large question. I agree that access is a problem, for all the reasons the Deputy noted. It is the metrics, and what taxi drivers tell people. It is well understood, and therefore, it is a priority.
In the short term, we as a board would focus on two things. One is the need for programmes which directly address access issues at particular points. The second issue is that models of care need to shift to a model which allows rapid access and rapid discharge, so that the throughput of a system can be changed. Some of that is due to staffing levels, and some is about models of care.
We have been talking about setting up board committees, and we have agreed that and allocated board members to four committees. One is audit and risk, as one would expect. We will also have a people and culture committee, which will look at strategic HR, and will do more than a traditional remuneration committee. The quality and safety committee will examine everything from the never event space, as well as whether we are delivering the outcomes we should at the right levels. The performance and delivery committee will look directly at metrics, including waiting times and access as well as whether we are delivering the number of procedures we said we would for the cost we said. We will have those committees. Two of them are specifically focused on a patient-oriented point of view, while the people and culture will focus on how to make this the best place to work, as well as somewhere that delivers the best health outcomes.
I welcome both the witnesses and wish them the very best in their roles. Mr. Devane referred to the issues of access and capacity. The first recruitment moratorium was introduced in the HSE 12 years ago. By way of context, I happened to be a trade union organiser at the time, and we were engaged in an industrial dispute with the HSE about what the Government of the day was doing in with that moratorium. We are feeling its effects now, and will continue to feel them for quite some time. At the time, we were given to understand that the board had relatively little, if any, involvement and that it could not take a position or view on the moratorium. However, from what Mr. Devane said about the establishment of these committees, it seems his intention is to be proactive around issues of access, human resources, people and culture, and so on. I would have called it industrial relations, but one may use whatever terminology one chooses. The HSE board has not traditionally been very hands-on, although it should be. Is it Mr. Devane's intention that the board will have a proactive role and will assist with issues of access? It has been 12 years since the moratorium was first introduced and its impact is still being felt to this day. There was a genuine belief among workers at the time that the board should have stepped in, but it did not.
Mr. Ciarán Devane:
I am probably not qualified to speak about that time, but the board's intention, at a strategic level, is to address both this and how to support the great staff of the HSE, who do great things every day, to do even more great things.
That has to be part of our role. There are other aspects which are within the purview of the Department of Health or the Department of Public Expenditure and Reform. However, as a board we have to ask how to deliver the outcomes that the public and the system deserve. We should not be ducking that question. In my experience, a health system can have structures and policy but it is really an ecosystem of people.
Mr. Ciarán Devane:
Therefore, how people work together and how the relationships between community organisations and acute organisations work are at least as important as the structures we decide on. Any good board needs to think about people and staff skills, staff shortages and consultant recruitment pipelines. That has to be a part of what we worry about. Other people will be influential in that, but if it is a critical success factor for what we are supposed to be delivering, we should be opinionated about it.
That is welcome. I will give my view and I am not suggesting for a moment that Mr. Devane shares it. The Government's commitment to Sláintecare has been fairly weak. The appointment is very welcome but the money put towards it indicates there is no massive interest in implementing it, notwithstanding the cross-party support for it. Sláintecare needs to be driven from the very top as will not succeed otherwise. In the two years since the Sláintecare report was published there has been no discernible progress with regard to it. The Sláintecare report did not just call for a shift to the community, which is really important. It called for the elimination or phasing out, or whatever phraseology we wish to use, of private care from the public health system. I am interested in Mr. Devane's view of privatisation in the health system, by stealth or by Government policy via the National Treatment Purchase Fund, NTPF, or the various other ways the public service is undermined, chipped away and hived off into the private sector. In my opinion this does not represent good value for money. I am interested in Mr. Devane's view of private healthcare versus public healthcare. Sláintecare includes a very clear commitment to moving away from private involvement in public hospitals and towards public delivery of care.
Mr. Ciarán Devane:
The strategy is clear. It says what it says and I do not want to question that on day three. Starting from the premise that the HSE is a public service, we should ask what conditions we need to ensure our mission is delivered as well as possible and what can support or get in the way of that. How we interact with private providers of equipment, pharmaceuticals or clinical services is a key part of that. From experience, the difficulty arises when the two get muddled up and one is not clear which is which. Perverse incentives then appear. It might be unclear, for example, whether an operating theatre is being competed for within a particular institution. If there is a vision for the end point, we should first ask what gets in the way of delivering great services today. How can we make the best use of this theatre and what is preventing us from doing that? I would start with the outcome. Are we restricting access in the public service, which the taxpayer is paying for, in some of the things we do? I would start from that point.
If private care is carried out in a public hospital, access is restricted by necessity. In cases where access is restricted, does Mr. Devane see it as his role to be proactive in ensuring that private care moves out of the public system? I cannot envisage any scenario where private activity being carried out in a public hospital will not interfere with public access. Let us start with the premise that this is happening. We know it is happening and Sláintecare says private care is going to move out. Presumably, Mr. Devane has a view on that.
The Sláintecare strategy says that this is what we are going to do and we will do it until the day we say we are not going to do it, for the reasons the Deputy implies. We have to make sure that the €16 billion of taxpayers' money which is being spent is used as effectively as possible. That has to be the starting point for everything.
If I was to jest, I would say I am sorry for his troubles. He has certainly taken on a very important and significant role. I was a big supporter of bringing back the board of the HSE. I also lobbied the Minister for Health, Deputy Simon Harris, to have the chairman of the HSE appointed first so that we could work with that person on the board itself. In fairness, the Minister took my views on board and did just that. One more position has to be filled and people from a broad rage of disciplines have been brought in, which is good. There is a good spectrum.
We have not had consistency of approach for many years. We need somebody who is committed to this for the long term. Does Mr. Devane envisage being in the position for the long term?
Very well. I am very taken by Mr. Devane's statement on priorities in his submission. He refers to developing and implementing an effective performance management and accountability system in the HSE. The previous acting director general, Mr. John Connaghan, appeared before this committee to address the CervicalCheck controversy. Once the Scally report had been concluded, which it now has been, there was to be a review of what happened internally in the HSE. I presume Mr. Devane supports that.
Mr. Ciarán Devane:
There should be learning from every clinical incident, system failure or however we describe it. Learning and accountability form a part of great clinical governance. That is one of the reasons we set up the quality and safety sub-committee of the board. We must do our bit to support a culture of great clinical governance, learning from the past but also learning what we can from other sectors. Everybody talks about the airline industry. My background is in chemicals. We all have experience of dealing with high-risk situations and we have to bring that to bear. The answer, therefore, is "Yes".
Mr. Ciarán Devane:
Yes, it does. We should have transparency and open debate on how to make things better. I am talking not about blame but about asking how we learn, improve and avoid putting people in a position where the wrong things happen. If we accomplish that, public confidence will go up. If we have predictable finances, public confidence and political confidence will improve too. Deputy Donnelly mentioned access, which is also related to this. Our performance will ultimately drive confidence. It is not really an activity in itself. If we get things right, people will back us and if we get things wrong, people will forgive us if we learn the lessons and will not forgive us if we do not.
I will ask a few other quick questions before concluding. I will be very disciplined for a change. People are the HSE's biggest asset.
What will we do to attract more people and retain those we already have? What will happen to the structures underneath the board? There are subcommittees and so forth, but what other changes does Mr. Devane propose to introduce? Structural realignment of the HSE is required across the country. That has been called for under Sláintecare, which we in this committee spent 11 months developing. I am in favour of the HSE's realignment; it needs to be done. How will Mr. Devane's position evolve in terms of board responsibility for budgetary management?
Mr. Ciarán Devane:
I thank the Deputy for his questions. There is something around communicating the vision of the future, the picture of a high-performing, place-based and integrated care model HSE of the future, and giving staff the space to move from here to there. Previously, there have been great visions but everyone has been running so fast just to cope with day-to-day work that they never get fulfilled. A part of the issue is ensuring that, if we want to address an issue, we have the structures and approaches that provide people with the time and resources to think their way to the future as opposed to just leaving it as a picture of the future with no path to it. Sometimes, health organisations are almost too efficient. Everyone is running around the hamster wheel so quickly just to cope with the peaks in demand that there is no space to move. People, in particular health professionals, are motivated when they can see how improvement is happening and they are not just coping with day-to-day work. If we can help with that, it will form part of the work.
I am into integrated, place-based healthcare so that the link between community and acute in terms of public health, physical health and mental health is tight. The real improvements will not take place in performing a unit operation slightly better. It is great if a unit performs a surgery a little better, but the real benefit for the future will be in terms of how the community links to acute, how we ensure that mental health services are involved at the right time and how the support package is delivered. That is how we get into the prevention and integrated side. The thinking behind community health organisations, CHOs, regional integrated care organisations, RICOs, and hospital groups rather than individual hospitals is directionally correct.
As to whether I see the board having budgetary responsibility, the answer is "Yes". We must provide the best possible healthcare for the money available. We cannot spend money that we do not have. Getting to that kind of financial predictability would allow us to, for example, tell people that we wanted to implement the next tranche of Sláintecare and that they could trust us in our budget estimates, since our budget had come in where we said it would. That is a place that we are not at currently but that we must reach. How else can we reassure people that we will land a very complex system on a postage stamp if we have not already demonstrated something like that?
I welcome our guests and thank them for appearing before us. I wish Mr. Devane well in the job that lies ahead. It is a challenging job at a challenging time.
I have been critical of the performance of the HSE since it was first instituted. That criticism was warranted, as we have not had a seamless and smooth system of delivery of services to patients, who are the people who matter. Notwithstanding that, we have the fourth or fifth highest level of expenditure on health among OECD countries. We need to reach a point of being able to ensure value for money, effectiveness and efficiency in our service. Sláintecare will do that, provided that we can achieve it.
Previously, my concern was that the HSE was remote from some of the institutions over which it had control in terms of the delivery of services. Similarly, many HSE staff throughout the regions and at its centre were unsure about where they were supposed to be going, what they were supposed to do, who their bosses were, at what stage they should use their initiative and at what stage it might be dangerous to use their initiative. I have been concerned about this from the beginning. I used to be a member of a health board, and the health boards were the opposite in that regard. They were abolished because politicians were involved. That was a woefully wrong decision. Events have since proven that my conclusion was correct. The exclusion of politicians took away from the institutions of the health services the support that came from local politicians and the responsibility that was forced on same by being in a position of authority. There were two sides to the story. There is an issue for the board to deal with in that regard.
There is now a single board for the whole country. I still have my doubts about that. The extent to which the board can extend its remit to the furthest extreme of the HSE's institutions and realm will be very important. That has not happened in the past. I asked the board's first chief executive whether he believed that the proposed structure was the appropriate method of delivering health services to a population the size of Ireland's, having regard to its geography rather than to the situation obtaining in the greater Manchester area, which was the comparison at the time.
We will all give Mr. Devane the support he deserves in trying to do a job that has been very challenging in recent times. Everyone blames everyone else. That is the problem, but it is the nature of the game. We have a responsibility. If we are spending a great deal more money comparatively speaking than many of our colleagues across Europe, we must be able to say that we are at least on par with their average. We cannot be behind. That is the challenge and I wish Mr. Devane well in it. As far as we all are concerned, we will do our best to help.
Mr. Ciarán Devane:
The Deputy's point about the kind of board or HSE that is remote from the lived experience of service users and patients across the whole of the country is well made. One of the matters that we will be considering is the question of how, when we achieve integrated care regionally and locally, we ensure engagement with communities, public and local stakeholders, including politicians. That is right. This is the other side of transparency. We must be able to get and listen to feedback as well communicate what is happening and what is or is not possible. The principle of subsidiarity is important in that regard. My vision for the HSE is not one of everything coming up to the centre and then going back down again. Rather, it is about how to enable the local organisations to work well together and deliver the best possible healthcare locally while also ensuring that everything adds up. The Deputy's point was well made and I thank him for it.
Mr. Devane is a very capable man with a great curriculum vitae, particularly in healthcare and in regard to the NHS and so on. Does he think a behemoth such as the HSE can be effectively chaired and governed by people who are not full-timers?
Mr. Ciarán Devane:
I do. State boards, being non-executive, are not populated full-time. We are not trying to be the executive. If we become the executive then we cause confusion. I am not the chief executive. Rather, my job is to hold the chief executive to account. There has been sufficient time input in that regard and the committee has my commitment to ensuring there is sufficient time input. Over the last nine months while I have been in shadow form, I have demonstrated that. What I must not do is imagine that I am second guessing the chief executive and the executive. If we do that, we end up with an organisation with two competing chief executives such that the clarity needed would not be there. When one's day job is being a chief executive one has to learn to sit on ones hand and sometimes choose not to say things and not be opinionated when one might be privately opinionated.
In terms of the oversight and accountability required of Mr. Devane in respect of the full-timers, would he agree that mental health services in particular have been the poor relation when it comes to spending in recent years? I refer to the child and adolescent mental health service which is struggling to respond in a prompt and timely manner to children who are at risk of self harm or suicide and to the long waiting lists for psychologist appointments as approximately 20% of consultant psychiatry posts are unfilled and one third of those in such posts are locums. We have a very unsatisfactory situation with regard to mental health services and provision. There has been a huge reduction in the spend in this area as a percentage of the overall health budget versus what we spent in the 1980s or even ten years ago such that are issues of real concern around mental health in particular. Would Mr. Devane agree with that and has this issue come across his desk yet?
Mr. Ciarán Devane:
It has not yet in this context but I have seen it before. I do agree. In many jurisdictions, mental health is an issue because it is complicated and hard to measure. One cannot stick a thermometer in a person's mouth and make a diagnosis. In light of this complexity mental health services have lagged in other jurisdictions as well. There is nothing the Senator says that would be inconsistent with that. I agree there is an issue. How we do the catch-up is the issue. Some very good work was done across the water around mobilising the mental health charities, working with collaboration with the health service, to change the social perspective on mental health. What we learned through that work was that the issue was pre-clinical rather than clinical services. Where there is early intervention there is less need for the psychologist, the psychiatrist or the mental health services later on. I have no reason to believe that would not be true here as well.
There are certain objectives related to clinical provision in respect of which we are lower than the EU average. In fact, we are lower than countries we would regard as much poorer than ourselves in terms of inpatient beds in psychiatry and, as I mentioned earlier, consultants. The charities cannot deal with those issues.
Mr. Ciarán Devane:
They can set the tone and the expectation. I will try to broaden the point. I ran a patient organisation, which did not receive Government funding. We raised money and funded innovation in services. In terms of collaboration between the HSE, the system more broadly and the voluntary and charitable sectors there is a lot that can be done to make sure there are coherent strategies in mental health, cancer or diabetes. Bringing in the voice of the patient allows for a more implementable, fundable strategy as well. One of the things I will be looking for is a mechanism to do this. I saw this work very effectively in the mental charities in the UK, specifically England. The charities work very well with the health service in terms of encouraging the non-mental health providers to recognise the need for early intervention and to then reduce the burden. We then can make sure we have enough consultants, psychologists, etc., in place, inclusive of mental health workers in the community.
In announcing Mr. Devane's appointment the Department of Health mentioned that one of the priority issues for the board would be delivering effective and safe services within the resources allocated. Mr. Devane, rightly, highlighted the issues of learning and accountability. I would add to that the issue of transparency. An issue that arose early in the committee during private session is the question of whether the investigation into the death of a child in Holles Street arising out of a termination of pregnancy-----
-----about an issue of public concern. It relates to the investigation into a particular death at Holles Street, which is of considerable public concern. There has been a lot of talk about in the media. I want to ask Mr. Devane what his understanding-----
Mr. Ciarán Devane:
The appointment is in process. It is a departmental-ministerial appointment, not a HSE appointment. My understanding is that it is in process. As soon as the right person is found the appointment will be made.
I had intended to ask Mr. Devane to elaborate on the public trust and confidence issue but he has already covered it in his interaction with Deputy Kelly. On Sláintecare, which has been referred to aspirational and over-ambitious, does Mr. Devane believe it is implementable?
Mr. Ciarán Devane:
Yes. There is nothing wrong with being aspirational. If we are sitting here in two years' time and we have done 30% of it, we will be saying that is great and what is the next 30%. I am sure the vision will be getting more ambitious as we move on. If we can get to a place where we have data driven, integrated care, place based with the right levels of access that will be a fantastic place to be.
I am one of the people who has the attitude that we should aim high and get as close as possible and then we can worry about the last 5% on another day.
I thank Mr. Devane for his presentation. I have a number of specific questions about what has occurred over the past four to five years and how the chairman sees it going forward from now. I refer to employment in the HSE. The number of people employed in the HSE has gone up by 15,954 people since December 2014. That is a 15.48% increase. I am concerned about such a large increase in staff in any organisation because one would imagine that there would have to be a strategy around what needed to be prioritised, what needed to be planned for and how this could be funded into the future.
I am concerned about the increase in managerial and administration staff. There has been a 15% increase overall in the entire HSE staffing levels over the past four years and three months but the number of staff employed in administration and management has increased by 24%. It has gone up from 15,112 to 18,751. That is an increase of 3,639 in four years and three months. The increase in front-line staff such as nursing has only been 11%. To me, that suggests there is no strategy. I do not understand why there has to be an increase of 24% over four years and three months in administration and management. Will the board set out a strategy to look at the issue of employment within the HSE to examine where we have a surplus and excess numbers and where we have shortages? It appears that whoever shouted the loudest got the staff and I am concerned about that. If one looks at those 15,954 extra staff, that costs €650 million a year at a rough estimate. That will not disappear in the morning; it will be an ongoing cost into the future. What will be the board's role in setting targets and achievements?
The second issue I have with the HSE is with no one wanting to take responsibility for decisions. I have learned of an incident where a particular issue arose in a particular HSE facility. The person who was in charge of the incident reported it to the person who was overall manager and the overall manager felt it was necessary to go up the line in the HSE, almost all the way to the top, for a situation that was well under control. About three or four other people from the administration side got involved in decisions being made on the medical side. It does not make sense to me that even though the person who was the overall manager of the particular unit was in charge, that person felt that they did not have the capacity to oversee the process that was ongoing. That sounded to me as though the big problem within the HSE is that no one seems to be able to make a decision and that it must go up along the line all the time. That is causing huge delays and frustrations in making decisions. How can Mr. Devane focus on trying to change that type of approach to dealing with issues?
Mr. Ciarán Devane:
We want to understand the people strategy, the numbers and the recruitment. We want to make sure we recruit people we can afford, not those we cannot afford, and that we recruit people who we need rather than those we might not need or where there may be another way of doing it. We will ask ourselves if we have the right people strategy for the HSE. There is always a temptation to fix an issue by hiring another body, whereas actually it could be possible to ask an existing staff member to solve that issue. We will ask the executive to outline what our overall people strategy is to make sure we have the right skills, people and pipeline in place because workforce is a major issue in most jurisdictions, the roles are changing so quickly and the specialisms are changing so quickly that it is difficult to even catch up.
I recognise what the Senator is saying about accountability in the example he has given. We have to create an environment where a unit manager feels that he or she owns the whole problem and can make the right decision, that he or she has the support behind him or her and can access the expertise if he or she needs to but does not need 15 other people to meet and discuss it. That is often what patients want. They want someone to take on their issues. People respect that and we have to give our staff the confidence that they will be supported to make the right decisions. This goes back to the issue of learning and safety. Across all health systems, we hear time and again that complaints come in, not because people just want to complain but because they want to be heard, they want someone to listen to them and they want to make the process better for the next person to come through the system. A lot of that comes down to individual accountability and empowerment. Those two go together and then we must support people to make the right decisions. On the odd occasion that something goes wrong, it is not about blame but about learning so that it is less likely to happen the next time. As a cultural intervention, there is something in that.
Mr. Ciarán Devane:
I would need to look into the notes on that to be honest. If it is a role which concerns the integration of care between primary care and acute care, and that person is non-clinical and is classed as a manager, that is still a good investment. If it is a case of shifting the focus away from the front line and disempowering people in the front line because someone else is looking over a staff member's shoulder, as per the Senator's example, that is less of a good investment. We need to get into the specifics and the detail of that. The Senator's caution about the overall rise in numbers and the shift in the ratio is a point well made.
Before I bring in Senator Dolan and Deputy O'Connell for their one question, will Mr. Devane be seeking specific funding in the next budget for the implementation of specific projects in Sláintecare?
Having looked at the Sláintecare process, one of the essential elements is information and communications technology, ICT, and developing an individual health identifier and an electronic record in order that real-time data can be secured and so that patients can be followed as they flow through the system. Mr. Devane might comment on that.
On the filling of vacancies, as Mr. Devane knows, there are up to 500 consultant vacancies at the moment but I refer to vacancies in general. The complexity of filling a post is highly onerous and to hire a mental health nurse, for example, one must go through 25 steps and if there is a blockage in any one of those steps, the appointment is delayed. Perhaps Mr. Devane will comment on how we will address the filling of existing vacancies in the HSE.
Mr. Ciarán Devane:
Some of the Sláintecare activity is already funded and is within the envelope. There will be other matters within and outside the HSE where we will be asking for extra funding. That debate will continue.
I take the Chairman's point on ICT and data. When I was working with Macmillan Cancer Support, we were big for a charity but small compared with the health service. I always said the best £1 million we ever spent was on data because we understood the cancer patients far better when we were able to link their NHS numbers with the cancer registries and with research we had done. I agree absolutely in respect of patient identifiers.
What we can do now and in the future with data will really help the patient journey because we will understand the human and not just the condition. I missed the Chairman's final point.
I will honour the Chairman's request to ask only one question. As a prelude to that, I want to pick up on some of the things Mr. Devane said. First, however, I wish him the very best. Deputy Kelly said he was sorry for Mr. Devane's troubles but they are troubles that belong to all of us if what the HSE is doing does not work, particularly those of us who need health services. That is the bottom line.
Mr. Devane referred to making clinical governance great. What about social care governance? The HSE must continue to improve health outcomes for the public in the future and give staff space to work with as distinct from just coping with demand. We cannot spend money we do not have.
In reply to a question from Senator Mullen, Mr. Devane stated that charities can set a tone and expectations. Mr. Devane referred to collaboration between the HSE and the voluntary charitable sector and indicated that much can be done there. He also spoke about looking for a mechanism by which to bring more patient voices into consideration. I think I am reflecting what Mr. Devane said fairly decently. He also made some comments following Senator Mullen's contribution about the mental health sectors. There were references to safe service within the budget. When Mr. Devane was talking about the time he spent working for Macmillan Cancer Support, he indicated that the best €1 million it spent was on data and understanding the needs of the patient. There is a whole range of chronic conditions to consider.
This committee had the new chief executive, Mr. Paul Reid, before it two weeks ago. He brought with him the memo he had issued to his staff on 14 June. The simple message was that holding the line on the budget is sacrosanct. We must build up the trust and confidence of our funders, of those who need the services right now and all of us who will need them one day. Everyone needs that assurance.
There are governance quandaries in respect of these things and that is the point to which I am coming. Mr. Devane is not the provider, he is the head of the governance structure that is there to provide the services. I am trying to pick between the two of them and not unnecessarily drag Mr. Devane into questions about what he is doing in respect of this and that. There is a distinction between being provider and commissioner. We had a system, in the early 2000s, in the Eastern Regional Health Authority, ERHA, whereby the commissioners and health boards were the providers. It was thought that was not necessary.
The UN Convention on the Rights of People with Disabilities includes a whole section on mental health and it has now been agreed that this will be implemented by Ireland. There are governance elements to that convention and the political conundrum relates to the interpretation of what is "urgent" and what is "critical". I am not against strong lobbies but our bodies work when and if we have balance between different elements. How is there balance, appreciation and an appropriate weighting between the strong, established, powerful areas and other areas which need advocacy and support? Mr. Devane touched on this when he was talking about mental health but which organisations and groups can be of assistance outside of the health area, where one would prefer to be starting? We need governance that is beyond regulatory compliance.
That is a medley of the issues. How will Mr. Devane, as chairman, and the board manage all of those competing pressures and tensions, and the lack thereof in some places? The edict to hold the budget applies to people with disabilities and chronic illnesses, anyone and everyone. We will wait while one service provider earns the respect of other public bodies. I find that unacceptable.
Mr. Ciarán Devane:
It is a challenge. Senator Dolan is absolutely right to ask about the people who do not have a voice and are not heard. We need to be very alive to that in the manner in which the HSE, more broadly, and the board, in particular, engage. People across the health sector traditionally use the example of the power of the acute hospital at the expense of its community equivalent, or the power of the physical health lobby over the mental health lobby and so on. We need to be acutely aware of that.
One solution, of course, is that many of the things we need to do are common. I will give another example from my past. One thing which worked very affectively in my Macmillan Cancer Support days was establishing a group of ten charities which covered multiple conditions. Of course, every time Macmillan talked to the Department and said it wanted an early diagnosis for cancer, the Department would say that it could not give it to Macmillan alone and that if it gave an early diagnosis to us, it would have to give it to everyone because otherwise it would be discriminatory. However, when we then went in as ten organisations and identified a common theme of early diagnosis, whether for diabetes, mental health, multiple sclerosis, cancer or whatever, people paid attention. One could partly get one's head around the problem and decide to focus on early diagnosis across all conditions. We then came in behind that as what was known as the Richmond Group of Charities.
There are ways of doing it if one leaves one's tribal hat out of the equation. I tried very hard to be seen not as a cancer chief executive but as a health chief executive. My colleagues in the British Heart Foundation and the Neurological Alliance tried to do the same thing. We all tried to say that while, of course, we had to fight for our constituency, we were much more likely to be heard if we worked collaboratively. That is one answer.
On the question on respecting the budget, we must respect the budget and cannot spend money that has not been allocated by the Government and the Oireachtas. We should not be doing that. We should be ensuring we spend that budget as effectively as possible. The settlement between last year and this year was good. We will travel to the end of this year optimistic about the settlement for next year but we want the credibility of telling the Government which gave us that money that we spent it brilliantly and did not spend money that was not given to us. We could then ask the Government to fund other things as well, whether Sláintecare, addressing a shortage of clinical mental health staff or whatever. We cannot surprise the Department or the Government by saying that we went off and spent more than the amount allocated to us. We are coming off a graph that is going up in any event. That is about us having a financial grip on things that would give the Oireachtas confidence that, if something is funded, the money will be spent well and money we do not have will not be spent. I hope that will allow the Oireachtas to state that it wants to give the HSE more money because it did a good job with the money it was allocated.
From the experience last year, we should not be in a position of coming up with a supplementary budget with a gap larger than in most jurisdictions with much larger budgets and populations, both in terms of a percentage gap and an absolute gap. We have a job to do that must be done in a way that does not damage the fundamental interests of the patient or service user. That is our challenge.
Yes. The same as previous contributors. I welcome the chairman. It is nice to have a Sir at the committee; it will be the first and last time.
I am happy, I think, about the re-establishment of the board. My only concerns are that there may be another layer in place. A narrative exists among the public, where true or not, that the HSE is layer upon layer of administration. I refer to Senator Colm Burke's comments and that manifests itself in an imbalance in recruitment, which feeds into the same narrative. I wish the chairman the best of luck. We all await effective performance and accountability. I am deeply suspicious of this "need to have a conversation with somebody" approach to underperformance, but I suppose it depends on the style of conversation.
I understand the chairman is a chemical engineer by background.
He is obsessed with cutting out steps and processes and I look forward to that being reflected in the health service. Many of us sat on the Sláintecare committee. Core to the plan is access to healthcare based on need not ability to pay. We saw so much evidence of the drag and inequality in the service. I assume that the chairman worked in the NHS during the introduction of the Agenda for Change system.
I worked in the NHS in the south of England when I was qualifying as a pharmacist when Agenda for Change was being introduced. It had its problems and did not completely work out but there are lessons from Agenda for Change that can be applied to the system here. One of the benefits of coming late to the table is being able to do things correctly and learning from other jurisdictions' experiences.
Improving patient outcomes is the whole point of the health service. One must focus on the people and culture, human resources, industrial relations or whatever one wants to call it. It is very difficult in the health service where there are things such as recruitment embargoes or moratoriums being introduced. They are blunt instruments. If one stops recruiting consultants and there are support staff wandering around with no direction, it might save money on the budget this week but it can have a negative effect in the long term. The approach we have had of cutting spending on pay by imposing recruitment embargoes is an ignorant tool.
Finance is a constant issue in health. The graph is going up. It is important to note that demand and demographics will always push the graph up, at least in the short term until the improvements to health over a lifetime bear fruit. We have a huge issue with the cost of drugs, including orphan drugs, and with pressure where, as Senator Dolan noted, those who shout the loudest get the most. I am greatly concerned that where we have a very robust system of authorising drugs, sometimes there is political pressure or those who have the loudest voice lead to exemptions being made, over others who require other medication or treatment who have no voice. The key to success is ring-fencing or some control on drugs spending annually, so that when the money is gone, it is gone. That has to be balanced with the pharmaceutical companies knowing how much money is in the basket to start with.
On contingency, last year the Termination of Pregnancy Act was passed. Hopefully free contraception will be coming down the track. Those should be once-off payments on the balance sheet.
I refer to the chairman's history at Macmillan. I am greatly concerned about the privatisation of certain segments of our health service, including primary care centres. Does the chairman see his background as being beneficial to a health service or is he insufficiently familiar with the Irish health service to say? Does he think that having charitable organisations or private companies managing certain sectors is the way forward or does he feel they merely have a role to play? The NHS is a public service. When I worked in it there was no private provision but there is a move towards private provision now. I am concerned with the mindset.
Mr. Ciarán Devane:
My response would be similar to that I gave Deputy O'Reilly, I am a public sector, public service supporter and fan. The private sector has a role to play but if one takes the American model, it does not deliver the health outcomes. It is vastly more expensive and with a lower life expectancy. Why would one want to implement that?
I wish to reassure the Deputy about layers of administration. We are going to examine this soon, and will ask if it is a question of subsidiarity, how do we get accountability as close to the front line as possible and how we support individuals, as Deputy Durkan noted. There is the question of remoteness. We must ensure that the HSE is neither some small body in Dr. Steevens' Hospital or some remote behemoth that sits over the people who do the work. That is really important. It is not a structural problem; it is one of communication, transparency, motivation and vision.
On pharmaceuticals, I understand there is a big push on biosimilars, which will address part of that. Keeping control of the drugs budget, while providing the drugs when needed, is a big challenge. The healthcare system has more people, living longer with more conditions and improving treatment, which is more expensive. The drivers of health inflation built into it, which is a problem of success, is very real. Health systems will never be cheaper because of that driver but they must be more effective. They must be more prevention-based, community-based and early intervention-based. If we can do that, we will then have the space to cope with the acute, chronic, and urgent and the unmet need.