Fintan O’Toole: Five things that the HSE is getting wrong

We have a native variant on the light bulb joke: how many simultaneous crises does an organisation have to create before it needs to be changed? If we’re talking about the HSE the joke is that there is no answer to the riddle.

Let’s consider five things that are currently going on with the HSE.

First, there are now 600,000 patients waiting for an outpatient hospital consultation, with some 137,000 of them on the list for more than 12 months. The figures include 100,000 children. These citizens are not waiting for treatment – they are waiting to be assessed. Which is to say waiting to be recognised as real human beings with real human needs.

The problem is not just the suffering behind these numbers. It is that this suffering has been entirely institutionalised by the HSE. Each one of those numbers represents a failure by the HSE to do its job and provide timely access to healthcare for the citizens it serves. But the HSE seems inured to that failure. It has been accepted as normal. Weary inevitability has replaced urgency and shame.

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Second, internal correspondence obtained this week by The Irish Times showed that the Ombudsman for Children, Niall Muldoon, has deemed the HSE guilty of “a profound violation of children’s rights” in relation to mental health and disability services. He noted that geographical disparities in care mean that “many children are punished for becoming ill in the wrong location”.

Third, the HSE has installed a spanking new payments system that – wait for it – is unable to make payments. Hundreds of small companies who carry out different kinds of work for hospitals and community health services have not been paid since March.

Everybody has long agreed that the HSE needed an integrated payments system. Minister for Health Stephen Donnelly said last September: “That work is being prioritised by the HSE leadership team. Without it we don’t have sufficient levels of operation clarity and financial clarity. Minister McGrath’s officials quite rightly want that. I want that.”

In 2019 the contract to deliver this system, worth €19.1 million at the time, was awarded by the HSE to DXC Technology. This contract was terminated by the HSE in March 2022, and a new contract was awarded to IBM. It is not clear how much DXC was paid in the meantime.

The first phase of this new system – involving most of the eastern half of the country – went live on July 3rd. Or perhaps we should say went dead. Hundreds of providers of hospital food and medical equipment, home-care and nursing home services, and maintenance and refurbishment work are finding it impossible to get paid since the great new system was put in place. Their invoices are not being disputed – they’re simply not being processed.

Some of these suppliers are small businesses now struggling to pay the wages of their workers. And because suppliers are not being paid, many of them have had to stop doing their regular work for the HSE. This is affecting the delivery of healthcare at many different levels.

It is also illegal. By law public authorities are supposed to pay providers within 30 days of the receipt of a valid invoice.

Asked about this situation last month by The Irish Times, the HSE said two things. One is that “no payments have been delayed and payments have been issuing to suppliers”. The other is that there were “currently some delays in processing around 25,000 supplier invoices to some parts of the HSE”. So, no payments have been delayed but 25,000 invoices have met with “some delays”.

This isn’t just gibberish. It’s a shrugging off of accountability. A self-contradictory “explanation” is, in effect, a refusal to explain.

And this is also what’s confronting the suppliers themselves. All calls looking for overdue payments are now routed to a farmed-out call centre whose unfortunate operatives know nothing about the HSE and can’t answer any questions.

Fourth, in a panic about overruns in spending, the HSE has resorted to an astonishingly crude mechanism: stopping all appointments of front-line administrative and managerial staff in hospitals.

A functioning organisation would evaluate these jobs and decide which of them need to be filled urgently and which do not. The HSE has simply applied a blanket freeze, which applies even when a role is vital to the delivery of care to patients and even when it is vacant because someone has been promoted or has retired.

There seems to be no effort to prioritise positions according to the actual needs of patients or to consider the real effects of leaving them vacant. People who were supposed to take up those roles have been informed that the HSE cannot tell them “when or if” they will ever do so.

Fifth, the HSE seems unable to deliver physical infrastructure that is fit for purpose. The saga of the new children’s hospital – already the most expensive hospital ever built in human history – is well known.

But consider perhaps the single most sensitive building in the entire State: the Central Mental Hospital. The new complex at Portrane was so cold last winter that patients and staff were wearing their overcoats indoors and then parts of it became “dangerously warm”.

None of this dysfunction can be fixed either by shifting the pieces of the HSE around or by throwing more money at it. In the 19 years of its existence the HSE has had five different structural “reforms”. It is not obvious if any of them has made the slightest improvement to its collective culture.

The Children’s Ombudsman identified one of the fundamental problems that seems, if anything, to get worse with each reform: “The lack of inter-agency co-operation has been a constant frustration and challenge for children and their families. The HSE has too many siloed agencies and services within their own aegis who do not, and apparently will not, work together to ensure the best interest of the children they are charged to care for.”

Note those damning words “will not” – there are managers who are so happy in their cosy bunkers that they choose not to work collectively for the good of the patients they are supposed to serve. And the reason they can rest content is that they know there is no accountability.

The HSE was established in part because it took accountability for failures in the health service away from the Department of Health and its ministers. But its creation did not effectively transfer accountability to health service managers. It just buried it under layers of obfuscation.

Who, for example, will have to account for the creation of a payment system that can’t make payments? When all of this is eventually examined by an Oireachtas committee, IBM will blame the HSE (and claim commercial sensitivity in relation to the details) and the HSE will blame IBM.

And who takes the pain for the systematic breaches of children’s rights to healthcare? We know the answer to that one too: sick children and their families are the only ones who will suffer. Preferably in silence.