Lack of effective accountability the biggest weakness in scandal-ridden health service
In 2014, the departing head of Hiqa, Dr Tracey Cooper, said: ‘The problem is we never had any consequences.’
IT has been a bad week for the reputation of the HSE. On Thursday, Tánaiste Simon Coveney and Health Minister Simon Harris apologised to Vicky Phelan, who is now terminally ill as a result of a threeyear delay in telling her she had a life-threatening cancer.
On Friday, it was reported that the HSE had apologised to Ciara Loughlin’s parents, Elizabeth and John, for failings in the care of their baby, who died shortly after birth in August 2007. These failings only came to light seven years later when they were prompted to enquire by an RTÉ ‘Prime Time’ programme in 2014 about the deaths of four infants in Portlaoise Hospital.
One of those four was Mark Molloy, who died in January 2012. On Tuesday, his parents Róisín and Mark, on emerging from a hearing of the Medical Council, spoke of their devastation at failing to secure accountability for their baby’s death after years of harrowing effort.
Earlier in the week, the headlines were about a young girl being left for years in a foster home when there was credible evidence that she and another child had been raped. Again there were apologies from the HSE and politicians on all sides, as there were last year after exposure of the case of ‘Grace’, an intellectually disabled child who was grievously abused in a foster home but whose tragic story has now gone off the radar to be replaced by the latest scandal.
Health care is a complex, risky activity and, while human error, incompetence or misconduct may sometimes be a factor, there is a pattern to these recurring tragedies that points to underlying systemic weaknesses which, if not addressed, will continue to spawn these avoidable disasters. A ‘root cause analysis’ would identify politicisation of the health service, anachronistic professional demarcations and change-resistant vested interests, a sclerotic legal system, lack of investment in primary care, a culture of concealment and other contributory factors.
The most malignant underlying cause, however, is the lack of effective accountability. When asked by Ivan Yates on TV3 last week whether ministerial apologies were sufficient to restore her trust in the system of cervical screening, Ms Phelan said “no”, adding that it was the people who were involved in her care that needed to apologise. “They have to be accountable,” she said.
Like Vicky Phelan, Róisín Molloy has called repeatedly for accountability, especially at managerial levels in the HSE and the Department of Health. The Hiqa report into the Portlaoise infant deaths cited managerial failures at several levels up through the chain of command, but the HSE will still not say whether anyone has been disciplined for these failings. “The matter is currently ongoing”, they say, six years after baby Mark’s death.
The process of holding the relevant managers accountable for enabling the abuse of ‘Grace’ to continue for years is also “currently ongoing”, meaning, in effect, that the process will be dragged out while those responsible are moved sideways, promoted or retired on full pension, all in the certain knowledge that over time the public will forget about it.
In 2014, the departing head of Hiqa, Dr Tracey Cooper, said: “The problem is we never had any consequences, so that if there is a systems failure or a problem with the quality of services, nothing really happens. Where there’s a repeated problem, there should be consequences.”
This is still clearly the case and not surprisingly since the CEO of the HSE is on the record, in commenting on the Portlaoise Hospital case, saying the HSE does not have the legal or HR instruments to hold managers accountable – that is, accountable with consequences arising.
The substantive work of management involves working on the business, as distinct from in the business. An important component of work on the business is continuous improvement in the core processes; in healthcare this means the constant streamlining of care pathways to improve safety, quality of care, patient experience and cost efficiency.
Process improvement projects pay particular attention to the ‘hand-over’ from one unit or professional to another, for example from the laboratory to the GP to the patient to the consultant, etc. The weakest points in the care pathway are at the hand-overs. That’s where the ball gets dropped.
In other settings, like the manufacturing industry, for example, the relentless pursuit of process improvement is a way of life involving wide participation of staff, all of whom will be acutely aware of ‘international best in class’. The reason for this high awareness is that their jobs depend on it; unless they can match or beat the best they may be out of business.
In this context it is depressing to hear ministers demanding a review of CervicalCheck “to ensure that it meets the highest international standards”.
THROUGHOUT the health service, there are squads of managers with grand titles like National Clinical Director, and consultants with a dozen letters after their name that announce their deep expertise. These people must attend continuous professional development programmes and, as professionals, one assumes they keep in touch with the relevant literature. If any cohort of staff anywhere ought to know about ‘best practice’ in their domain, it must surely be those holding leadership positions in the HSE.
What constitutes ‘best practice’ across every area of our health and social services is well known. They can tell you. But less clear is who is responsible and personally accountable for ensuring its implementation? Two years after ‘best practice’ for the treatment of sepsis was set out in response to the death of Tania McCabe, most maternity units in Ireland had not implemented the new processes, a deficit that may well have contributed to the death of Savita Halappanavar in University Hospital Galway. Which managers were responsible for that failure?
The Sláintecare report offers hope for longer-term transformation of the health service but it will simply never happen unless a culture of personal accountability is established, most especially for those holding managerial positions. To get started, here is a suggestion: at their next performance review (that is, if such a thing occurs), have the following questions posed:
■ Do you know what constitutes ‘best practice’ care pathways and treatment protocols for your immediate area of responsibility?
■ Do you know what constitutes ‘best practice’ in the hand-overs from your area to those with whom you interact, both internally to the HSE and external service providers?
■ Are these disciplines documented, implemented and compliance with them monitored?
■ What process improvement projects have you initiated?
In manufacturing and service industries across the country, most managers, from front-line supervisor to CEO, would be able to answer these questions.
If a simple improvement methodology, such as ‘Lean’, had been applied by the management of CervicalCheck, it is highly unlikely Vicky Phelan would be terminally ill, and she is not the only one. What Dr Cooper also said is still true: “We don’t know how many people we are killing or harming unavoidably”, and this remains the case because, “We still have not cracked accountability in the health service”.