OPINION:The crises in banking and healthcare have more in common than meets the eye: in both areas, a sense of vocation has been lost
IN THE absence of a 360-degree turn in mindset and policies, the next weeks and months will see unprecedented stresses on our health system. Looming industrial action, capacity constraints and a continued failure to manage the delivery of patient care provide a formidable challenge. Trust within the system is at an all-time low.
There is a startling commonality between the root causes and defects of the ongoing banking crisis and those that continue to gain momentum within our health system. There are lessons to be learned.
Firstly, rudimentary failures in risk management infected the balance sheets of financial institutions, leading to instability, failures, nationalisation, and the biggest financial rescue in history.
Analogous failures in risk management have been a feature of Ireland’s health system, encompassing services from blood transfusion, to oncology, to emergency care. They have been evident in systemic failures across our health system – from hospital-acquired infections, to the growing burden of avoidable chronic illness, and to the “smoke and mirrors” which have been used to disguise the shortage of capacity and staff, as well as to the growing instability within the private health insurance subset of the health system.
The collapse in the banking system was defined by failings in the corporate culture. Some years back, I listened to the (then) chief economist of NatWest Dr David Lomax, speaking at an IMI conference in Belfast, where he concluded that, “I joined a profession and ended up working for an industry”.
This transition – this transformation in the governance and motivation – of the financial services industry facilitated its subsequent capture by “dark forces”.
A similar process is evident in healthcare. A widespread acceptance of the vocational nature of healthcare has been displaced by a “command and control” mindset and creeping “managerialism”. Delegating responsibility to individual hospitals and teams has been emasculated by a form of centralism without accountability, with the HSE – which has its own difficulties – acting as “firewall” for the State, rather than a means of empowerment for those providing care.
The Irish healthcare system is not, and never was, “Angola”, as termed by a previous minster for health. Individuals want to go to work, albeit within a health system that does work. This pernicious myth has facilitated a misconceived approach to managing the service.
The term most commonly heard is “facing down” whoever happens to disagree with the current fractured, incomplete and inequitable system. The Health Strategy 2001 highlighted that spending on health should be regarded as “investment” with measureable economic benefits.The Government has chosen to ignore this and so the system is being made enormously worse by successive staff embargoes and cuts. The effects of all of this are evident in the specialised medical media, where data and articles on continued shortages in staff co-exist with advertisements from overseas agencies only too willing to attract medical and nursing staff who trained in, and now labour for, a health system they know is not working.
One of the most malign aspects of a very malign banking culture was its obsession with “targets”, reports and “short-termism” – and anything that would disguise the depth and seriousness of a near-terminal condition of some major institutions. Healthcare in Ireland is little different. Experienced nursing staff spend time they don’t have filling up forms we don’t need. You can’t be by a bedside and filling in a 27-page form (an actual example).
Targets are set, based on funding for the HSE, which incorporates largely mythological value for money initiatives (do the non-clinical management operating behind Government departments really believe their judgments about what savings can be safely made, are more informed than those who work at providing care?) and funding slashed before the ink is dry, in the full knowledge that such cuts impact directly on the quality of care and on lives.
The “short-termism” is reflected in the obsession with dealing with what gets a high profile in the media – such as the number of individuals on trolleys. In the next few weeks industrial action is set to escalate within the health system. Trust that could have helped resolve these disputes was squandered in the “resolution” of the nurses’ strike: a mean-minded “victory”, which sold the integrity and vocational commitment of staff short.
Trust was squandered in the demonisation of consultants and in the long drawn-out process for a new contract – which was not then delivered fully on. These are not isolated examples; an adversarial culture has built up, in which neither staff, nor patients, are respected. Otherwise you wouldn’t have women of 90 years of age on trolleys (an actual example).
It is a time for rebuilding trust and for leveraging the expertise and commitment of those within the system.
That is why, in seeking a replacement for Prof Drumm, we could easily have dispensed with the usual expensive rituals. In the almost 100 directors of nursing/matrons within our acute system, there are a large number of women (and the posts are filled overwhelmingly by women), who have all of the qualities needed to deliver care and manage the system efficiently and cost-effectively.
Unlike the mandarins, they know that care delayed is, as often as not, care denied. They understand that patients are more important than processes. They know the importance of working with others, of hygiene and of bed management. They don’t need to be told. They are usually to be found on the wards and they know what’s happening.
Prof Ray Kinsella is the author of Acute Healthcare in Transition(Oaktree Press, 2006)