Second Opinion: What do the HSE and An Garda Síochána have in common?

Even though the HSE is less than 10 years old and An Garda Síochána is in existence for 90 years, the organisations are uncannily alike in the way they operate. In fact, the new report from the Garda Inspectorate, Crime Investigation, could have been written for the health services. Just replace the word "crime" with "health" and the problems are the same.

According to the report, “crime prevention should be the number one priority”. I agree. Health promotion and disease prevention should also be the HSE’s number one priority and they are not. Almost all the budget is spent on treating disease and chronic health conditions.

The inspectorate’s finding that “crime prevention specialists are not always engaged at the early planning applications for major developments to provide advice about crime-prevention design”, also applies to the HSE. All new developments such as housing estates, parks and shopping centres should be subjected to a health-impact assessment. This rarely happens, with the result that many new developments have few safe places to play or to be physically active. New hotels often have well-hidden and inaccessible stairs so that guests are forced to use the lift.

Bad planning has engineered physical activity out of our daily lives, leading to ill- health and increasing pressure on the HSE.

The inspectorate report notes that “while there are clearly many hardworking members, there is no way to objectively measure performance”. Ditto for the HSE. One and a half million people are treated in Irish hospitals every year and another two million receive other services but almost nothing is known about health outcomes, other than for cancer.

The “perception that under- performance is not being addressed” in the Garda also applies to the HSE. Some Garda districts “operate almost as separate entities”, as do some hospitals and health services.

Many voluntary hospitals prefer to forget that they are funded by the HSE. High levels of autonomy in decision- making in both the HSE and the Garda lead to inconsistency, with people in Dublin getting one service and those in Galway getting another. Like the Garda , the HSE has “significant gaps in frontline supervision”, “duplication of administrative functions”, and “unnecessary bureaucracy”.

Key agencies

The inspectorate found that although there are many “opportunities for key agencies to tackle crime by joint working”, this does not happen often enough. There is an “absence of a statutory footing for partnership working” and that “legislation in other countries brings key agencies together”. This also applies to the HSE.

Every report into the faults and failings of the HSE since it was established has identified an almost complete absence of partnership working, joined-up thinking and multidisciplinary work.

When the HSE was established, 10 health boards looked after the health needs of four and a half million people. One national organisation was supposed to streamline health services and eliminate duplication and gaps. Unfortunately, the HSE got off to a bad start.

Designed by bankers, it quickly became top heavy, with fabulously well-paid advisers and new senior managers, with their new director and assistant director titles and bonuses.

Two new layers of senior management were added. Middle and junior management, and frontline staff, were sidelined and, as in the Garda, left to fend for themselves. This created mistrust and staff became disgruntled.

The system’s need to streamline services did not materialise for several years. Duplication of administrative functions was allowed to continue. What a pity that the 10 health boards did not have an inspectorate to identify the changes needed before the HSE was set up.

Like many public-sector organisations, the HSE and the Garda need reform at all levels. Unfortunately, reforms often start and stop at top management level, as if that fixes everything. It does not. All levels must be reformed simultaneously.

Both the HSE and the Garda need to focus on their junior and middle managers and to look after their frontline staff.

It took several years for the HSE to begin to look inside itself. It now has standardised clinical care programmes, which means that the 450,000 people with asthma and the 200,000 with diabetes should receive the same service no matter where they live.

Children and older people live in a safer world than 10 years ago. The HSE is now a slimmed-down organisation and, given time, may become a great organisation.

It should not be disbanded at this stage because things can only get better if reforms continue.

drjackyjones@gmail.com Dr Jacky Jones is a former HSE regional manager of health promotion and a member of the Healthy Ireland council