SECOND OPINION:The HSE needs to develop its own integrated culture
THE CULTURE of the Health Service Executive is seriously out of line with what is needed, according to chief executive Cathal Magee, and the organisation’s annual report 2010 highlights the “absolute necessity for reform and change”.
The HSE has had five years to bring about this reform and still hasn’t succeeded, despite having corporate plans in place since 2005. The problem is that the HSE doesn’t have one culture, it has cultures, plural.
As the annual report points out, the HSE is an amalgamation of 25 bodies and resembles a federation, rather than an integrated organisation with a shared identity. The use of the word federation is apt as it means one entity made up of a mix of self-governing entities in which self-government is typically entrenched. This is what is happening in the HSE. Each body that makes up the HSE has its own culture and, within each of those, each discipline has a separate culture.
It is well known that “culture eats strategy for breakfast” and this means that even the best corporate plan hasn’t a hope of bringing about change until the HSE develops an integrated culture. This involves keeping the best from each culture and getting rid of the rest. The way services are planned and delivered, with each department and profession doing their own thing, does not develop a unified culture.
Culture is the most important driver of any organisation. An unquestioned tacit understanding is transmitted through culture, which is “the way we do things around here”.
At the heart of all cultures is a world view or paradigm that decides how everything is done, regardless of what corporate plans say. This paradigm defines boundaries and tells people how to behave inside the boundaries in order to be successful in the organisation and their careers. Culture decides what rituals are acceptable, whose stories get heard, how power is distributed, and what controls and structures are put in place. The way things are done in the HSE, because of the un-integrated mix of cultures, is through endless meetings, unread reports, hero nurses, waiting lists, trolleys, turf wars, vested interests, competition, shabby buildings, parallel working, confusion of roles and massive bureaucracy.
There is a complex mix of cultures operating in every setting where health services are delivered. This is obvious as soon as you walk in the door. Look for it next time you avail of a service.
Signage is a good example of the culture in operation. Within every setting, each discipline has its own culture. Health professionals are trained in a discipline by others from that discipline. They then work within systems that pay lip service to team work. They learn the mindset. The way people are trained and socialised on the job means that those from one discipline find it hard to see health and health problems from a team perspective. Professionalisation is in direct opposition to team working and integration, which is the culture change needed throughout the HSE.
More than 50 years ago the philosopher Thomas Kuhn wrote about the circular arguments that arise when a health problem has to be solved. Each group of professionals argues in defence of their own world view and invariably talk through each other at unproductive meetings. None of this is good for service users who receive conflicting advice as a result. Anyone who works in the HSE knows this happens all the time.
Another philosopher, Hugh Petrie, wrote a paper in 1974 called Do You See What I See, in which he noted that the importance of inter-disciplinary working is seldom matched by its fruitfulness. He argues that we need fully competent disciplinarians with adventurous spirits. Unfortunately, the cultures of the HSE and the professions do not like adventurous people because they are a threat to the status quo.
These cultures have disease as their central paradigm, which is incompatible with the HSE’s mission statement. Over 95 per cent of the HSE’s budget is spent on treating disease and this is unsustainable.
The Policy Framework for a Healthier Ireland 2012-2020being developed by the Department of Health and Children, is an opportunity to put things right. In the meantime, Magee has his work cut out trying to develop an integrated culture, but success will mean better services for everyone.
Jacky Jones is a former regional manager of health promotion with the HSE