Medical Matters: Dysfunctional culture is prime reason for continued failure of HSE


It’s fair to say the generally accepted view of the Health Service Executive (HSE) is that it is a failed entity. Many who work for it provide a superb service to patients; however increasingly this is in spite of rather than because of the actions of senior management.

Speaking on The Last Word with Matt Cooper on Today FM last week, Liam Doran of the Irish Nurses and Midwives Organisation put his finger on the problem when he referred to a two- value system in health service management, “which divides the workforce”.

He offered this view as part of a discussion on the revelations of huge top-ups to the salaries of hospital CEOs and other senior administrators.

By their actions, senior people clearly believe they are a privileged elite. It’s an “us and them” mentality that means its acceptable to cut young nurses salaries in the name of financial austerity while a different “because I’m worth it” attitude ensures highly questionable bonuses continue to be discretely paid to those at the top.

The revelation that earnings from hospital sweet shops and car parking fees are used to benefit high-ranking individuals is especially odious and reinforces a sense of the benefactors being divorced from the “little people”.

Such cultural dissonance at the very top affects the day-to-day activities of our health service. It is so embedded that it even appears to impinge on the efforts of the HSE to deal with critical incidents. The death of Savita Halappanavar is a case in point.

When the case first came to light and the HSE/ Department of Health announced its own inquiry into the 31-year-old dentist’s tragic death, it saw absolutely nothing wrong with the inclusion on the inquiry team of four consultants from the same hospital where the patient had died. There was no malice intended: the decision simply flowed from a corporate mindset that has difficulty thinking outside a narrow frame of reference.

However the negative optics were such that the decision had to be reversed.

Last month, a special board meeting of the West/North West Hospitals’ group was held to consider all the findings from the inquest and two separate reports into Ms Halappanavar’s death. In a subsequent press release the group’s chief executive made the following statement: “Now that all three reports are available to me, I will apply our established disciplinary process. This will entail a review of the actions of all staff members involved in the care of Mrs Halappanavar...

“As part of due process, the staff will have full opportunity to explain their decisions and actions.

“We will take all appropriate action in light of these proceedings. I believe that in many instances there will be no case to answer.

“As part of the disciplinary process, if we believe it appropriate we will refer individuals to the Irish Medical Council and the Nursing and Midwifery Board.”

Which is as it should be where clinical staff are concerned. However there is no mention of investigating the role of health service managers in the press release.

It would appear the board believes that doctors, nurses and other front - line staff operate in a vacuum. That they inhabit a world where they control staffing levels, decide on the renewal/ purchase of diagnostic equipment, and control whether protocols are disseminated in a timely fashion.

But in reality it is health service managers who make decisions about consultant numbers, equipment and patient management protocols.

So will the managers who are responsible for these and other policy decisions be subject to the same review of their actions? Or, however unintentionally, will the aforementioned cultural deficit ensure this does not happen?

In my opinion, a prime reason for the continued failure of the HSE is that this dysfunctional culture is so deeply embedded and entwined in the organisation. Nothing less than its abolition can remedy this and provide a safer environment for our patients.

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