Tallaght Hospital boss fell victim to convoluted Irish way of doing things

Dr David McCutcheon arrived from Canada full of bright new ideas two years ago. He was determined to complete the merger of three Dublin city centre hospitals on a site in Tallaght. He achieved that goal but, six months later, he and his family are about to return to Canada. Where did it go wrong?

When the hospital board met last Tuesday night, chairwoman Ms Rosemary French told board members she had received a letter of resignation from Dr McCutcheon. She read it out. The chief executive said he felt let down by the Department of Health, that there had been a breach of trust in his relationship with it. The letter detailed his upset and disappointment at events.

When the chairman finished reading the letter, board members stood to pay tribute to Dr McCutcheon and afterwards gave him an ovation.

There was no doubting their regret. However, according to some sources, this was a board which could have done more to enlighten its chief executive on the ways of Irish medical politics. "He was the meat in the sandwich", was an oft-quoted refrain from those giving their opinion on what had gone on - stuck in the middle between the board and the Department of Health. Others put it more baldly. "He was screwed from all sides, not least his own board. Some of the experienced people on the board should have taken him in hand regarding what the Department of Health was saying and let him know what they really meant and the importance of getting things signed and sealed rather than taking people at their word. But they seemed quite happy to sit back and let him behave in such a trusting manner." A consultant at the hospital told The Irish Times that the chief executive was a good manager "who didn't quite get to grips with the Irish way of doing things".

"You can say he should have found out what was what, or you can say that it casts an unpleasant mirror on how we do things here. We are so used to the way things are done that we don't pay any attention. It must seem bizarre to a newcomer."

The Deloitte & Touche report on the hospital set-up, said the consultant, had actually contained few "hanging offences". "You may not like management meetings going on for hours, or that the board had a number of committees, but they were hardly serious things. What the board did do was take a policy to overspend, which it clearly signalled to the Department and was never told `no'. "

There are some people who believe that Dr McCutcheon was simply not a good manager, and, as identified in the Deloitte & Touche report, spent too much time seeking consensus. They point out that he took the Tallaght job after failing to get the top job at a hospital in Hamilton, Canada. He had been chief executive of a merging hospital there, but did not get the top job after the merger.

During negotiations with the Tallaght board he managed to secure a salary above that given to others in a similar position, receiving about £53,000 from the Department of Health and a balance of around £30,000 from the three hospital foundations, as well as money from Trinity College, where he had teaching commitments. His contract also allowed time for teaching commitments in Canada. His critics say he could ill afford that time when he was managing a hospital in crisis. One of the few people who would speak publicly this week was the chairman of the hospital's medical board, Dr David Fitzpatrick. He believed Dr McCutcheon's management style was "too advanced for the Department of Health to fully appreciate".

"He had much clearer ideas on a management structure for a hospital than we would normally see in an Irish hospital. Even though the Deloitte and Touche report criticised the multiplicity of committees which he had set up, they failed to appreciate that they all had a purpose, primarily to get the hospital up and functioning. The idea was that they would be reduced later. This was devolved management, even though he was accused of not devolving enough. A prophet is without honour in his own country."

No appreciation was given, said Dr Fitzpatrick, for the incredible achievement of successfully moving the three hospitals together. The most pressing problem facing the hospital has been funding, he said. "The Deloitte & Touche report identified that the method of allocation of funds was inappropriate to our hospital. They [the Department] took the budget of three base hospitals together, added a bit and said `that's your budget'. If Dr McCutcheon had a fault, it was in being naive and believing what he was told - if he got the hospital opened the funding would be looked after. That was said at meetings but if things are not written down... "

Another doctor, who did not wish to be named, said Dr McCutcheon had "played his best card" by getting the hospital open. "They [the Department] would have promised him the world just to get the place open in time." Morale among staff at the hospital is poor, with many people concerned about their jobs, according to a nurse. "There were rumours coming from senior administrators about layoffs and that 6 per cent had to be cut right across the board. There has been a lot of uncertainty for the past few months, nothing has been moving. Only eight of the 12 operating theatres are open. Staff who had other options were leaving. It is a pity, because the changeover was quite successful."

On a broader scale, the departure of Dr McCutcheon should open a debate on how Irish hospitals are run. Very large hospitals are a relatively new phenomenon here and their advent brought a different set of problems. On the one hand there is a chief executive who is largely administrative and involved in looking after budgets and accounts. However, hospital consultants, who have clinical independence, are largely able to treat whom they like, how they like, in some cases making a nonsense of budgets, according to one doctor. "It is like having a bank account but with someone else holding the cheque book. People with clinical responsibility have, by and large, consistently eschewed any financial accountability. They have their heads in the sand and if they continue that way, they will inevitably condemn the institutions to bankruptcy. There has been a tradition of autonomy and independence for clinicians. In reality, the spend has been determined by consultants, not administrators.

"You can't just say `I want to admit patients'. Clinicians must agree to sit down and set budgets and work out agreements in terms of admission policy. A guy could be doing all knees and no elbows, or all bladder and no prostate, and the hospital has little or no control over that."

Dr McCutcheon, he said, was the first of a new breed who bridged that gap between medical and administration. "It would appear he was extraordinarily effective in many ways. However, the administrative side saw him as a dangerous new departure, while the consultants were equally hostile. Now they can all go back to the status quo. Except that hospitals will have to become more businesslike. There is no point in having chief executives that are toothless." The hospital board is now seeking a bank loan of £8.5 million to cover last year's deficit. This loan was announced after the very public tussle between the board and Mr Cowen before Christmas. It certainly appeared as if round one had gone to the Minister, but the question now concerns what the board can use for collateral.

As far as Mr Cowen is concerned, it is up to the board to underwrite the loan. However, the hospital's public relations campaign could be stepped up a gear, with the board announcing that it has been refused the money. At the back of it all are the board's collective assets - the proceeds from prime city centre properties which they left behind when they moved to Tallaght. Despite what Department of Health officials may wish to happen, the board would be loath to dip into the money, charitable funds which by deed must be used for new and enhanced services.

The board will be presented with its £64 million service plan by the management team on Wednesday, when job cuts of more than 200 are expected to be announced, as well as the freezing of other developments at the hospital. It does not bode well for the hospital - the extended out-patient department lies empty because of lack of funds, casualty attendances are 35 per cent higher than expected, some operating theatres remain closed. For the future of the hospital, the departure of Dr McCutcheon has solved little. The problems of Tallaght Hospital are likely to continue.