HSE chief is to leave position after six years

THE head of the HSE has announced he will leave his on €186,000 position this summer after six years.

Tony O’Brien, who has served as director general since 2012, made his decision last summer and discussed it with Health Minister Simon Harris. He then formally confirmed his decision last week.

He sent out a video to staff yesterday outlining his reasons for leaving. Mr O’Brien acknowledged the ‘unique privilege’ to ‘lead the health service and its staff through its most challenging period’. He said: ‘We have managed to keep the health services running as efficiently as we possibly could... we have delivered increased services each year including those years when resources were still reducing.’

Mr O’Brien said on Twitter he is not retiring. ‘I’m planning to see a bit more of UCD. Unfinished doctoral programme to attend to,’ he wrote.

EVERY managerial departure creates an opportunity for someone else. As news broke at lunchtime yesterday that Tony O’Brien has decided to retire as the director-general of the Health Service Executive in the summer, it is not hard to imagine that many individuals pulled up their CVs and prepared to email them to the head-hunters the HSE is bound to hire.

It is a prestigious job with reasonably big pay at least by most standards. What qualified person wouldn’t want it?

Many, I suspect. This is the job that may be more trouble than it’s worth even at a salary of about €186,000 or possibly more. That may be a multiple of what nurses get, for example, but it is also a fraction of what a chief executive would earn at a commercial enterprise with a fraction of the staff and budget of the mammoth HSE. And which would not be as important. There are many good reasons to argue about excessive executive pay but is it a case of cutting off the nose to spite the face if the choice of suitable candidate is dictated by limits on pay?

There are issues, too, as to what type of person would be best qualified. Someone from a medical background, like previous incumbent Professor Brendan Drumm, on the basis that such a person would better understand the medical requirements of running the health system and the operations to do that? Or a professional manager, such as the short-lived tenure of Cathal Magee once of Eircom, who makes decisions based on financial and administrative needs to provide the best value for money possible?

And what about the political skills of the man or woman selected? The policy is set down by the Government of the time and its particular minister. Mr O’Brien had to deal with James Reilly, Leo Varadkar and now Simon Harris. The budget is controlled by the Minister for Finance. The boss has to deliver a wonderful service, as demanded by everyone, but so while staying within budget.

What is Mr O’Brien’s legacy? The HSE is consistently over-budget, in need of additional top-ups running into hundreds of millions of euro each year. The service, once people are able to access it, is regarded generally as top class, but a waiting list of about 700,000 for medical procedures and over 600 people daily on trolleys in EDs waiting for admission to one of our hospitals is a stinging rebuke.

There are many reasons for these relative failures, of course, and Mr O’Brien spelt them out in a 2,500-word article last year in The Sunday Business Post. In retrospect it reads like his resignation statement: a frustrated cry about the lack of appreciation for what has been achieved – and the work of many people – but also a plea for flexibility to allow change in how things are done and an appropriate budget to carry it all out.

‘In the absence of a collective societal and political willingness to make some of the hard choices required for change,’ he argued, ‘I question whether it is possible we can ever effect these changes and achieve a health system that can be truly operationally efficient, can provide effective value for money, and provide a worldclass care in health delivery.’

Outdated

His argument is too long to reproduce in full but anyone thinking of taking his job should read it in full. Here are just some bits of it that I’ve pulled out. Mr O’Brien argued cogently how ‘our health services construct is outdated and not fit for purpose’ and how the system ‘was designed for a time when we had a different demographic profile and the expectations around clinical governance and standards were not as they are today’. He suggested ‘we as a society have been too reticent to make the really hard decisions in order to fundamentally change it’.

That’s code for blaming politicians. He believed ‘many of our elderly and other cohorts of patients who now depend upon the acute hospital setting could be treated far better and far more appropriately in other settings – such as primary care and, where possible, at home’.

He argued that we need to ‘build capacity outside the acute hospital sector, in order to allow us to adequately manage chronic conditions. It also requires us to move services such as diagnostics, assessments and certain procedures that are currently provided in acute hospitals to the community setting’.

If that is to be done it needs money outside of the normal health budget – what Mr O’Brien called a significant transition fund is an absolute requirement. The idea is that this would allow existing services to continue and increase while primary and community care services are kept to the required capacity and standard. But the controversial part is where local politics gets involved. We have 49 acute hospitals and 28 EDs but many people agree with Mr O’Brien when he said ‘that is too many, and we will need to stop providing complex acute care at so many hospitals – where it is inappropriate to do so. We need to streamline the services we provide in the acute hospital setting, eliminate unnecessary duplication of services in hospitals within close proximity, and instead continue to develop centres of excellence. In some smaller acute hospitals today – for historical reasons – we see complex trauma care and other procedures provided in a situation where, from a clinical safety perspective, this should not be happening’.

Try telling that to local voters and their politicians when their hospital is earmarked for downgrade or closure. Mr O’Brien said ‘attempts to tackle these hard decisions require a type of political courage that is not often apparent. As the truism goes – all politics is local’.

He cited Roscommon Hospital as a good example. ‘It was an acute hospital providing a range of complex surgery and trauma care in circumstances where some of the clinicians in that hospital questioned the safety implications,’ he said. ‘We ceased providing that type of complex care and changed the role of the hospital to a more appropriate and thus safer service. This was undertaken while balancing a number of considerations including clinical risk, the economic impact on the local area and the maintenance of appropriate jobs for the hospital staff. In the background, too, was a vitriolic campaign by some local people. Polarised views arose, resulting in much heated debate and protest. Some politicians were ostracised, while others used the controversy to raise their profile.’

He might find it hard to get people in that area to support him publicly but he believes Roscommon Hospital is now flourishing, ‘providing less complex procedures but considerably more outpatient services, day surgery and diagnostic services to the people of Roscommon and its environs’. That example has not helped the HSE effect similar change at other hospitals in relatively low density areas; local politics and the government’s precarious position has seen to that.

I imagine Mr O’Brien will leave the HSE frustrated, given that he wrote that ‘for many years now we have merely tinkered around the edges of reforming a health service that has pretty much remained unchanged over the past 50 years. Year in year out, we are obliged to work with a system that, because of its design, is too expensive because we have failed to grasp the thorny thistle of fundamental reform. This involves courage, hard choices and looking beyond what we are used to’.

There will still be people who’ll fancy that job. Good luck to them. Their chances of success – in the absence of reform – are slim.