Patients and the public interest were at the heart of Prof Brendan Drumm's five years as chief executive of the HSE, but his tenure was coloured by frustration and 'groupthink', writes
MUIRIS HOUSTON
PROF BRENDAN DRUMM would not readily be identified as a disciple of Machiavelli. Yet the former chief executive of the Health Service Executive (HSE) quotes the 16th-century strategist approvingly in his new book. Although based on his experiences in the health service, Drumm's thesis in The Challenge of Changeis even more relevant to the wider public sector – which is where Machiavelli comes in.
Whether in banking, healthcare or other public services, he believes we have paid a heavy price in assuming the interests of the public and the Government are the same.
"If I am a member of a national governance structure in any public sector body, who is my major stakeholder?" he says to The Irish Times. In whose interests am I making decisions? Is it my responsibility to represent what is in the best interests of the public or am I first and foremost responsible for making decisions based on the requirements of the minister or government who appointed me?"
“A board member operating in the public interest should be responsible for challenging decisions that are not in the public interest but in doing so may immediately place themselves in conflict with the government and minister who appointed them,” he argues. It’s almost impossible, he concludes, for such board members to do the right thing. “What politicians and often governments want is that the system is managed, but not too effectively.”
He is scathing about our “national” propensity for consensus, which leads board members towards “unanimous votes and groupthink”.
If governance structures in the health system had been up to scratch during his five-year tenure as HSE chief executive, what difference would it have made? “Change would have been easier and quicker,” he says emphatically. “With no distinction between the operational and political systems, it is impossible for managers to operate.”
In his view, officials in the Department of Health were traditionally caught in cross-fire between politicians and lobby groups. “But when the HSE began to question the contractual arrangements that existed with various providers, such as the pharmaceutical industry, dentists and doctors, the question immediately arose as to why contractual relationships that were extremely beneficial to the suppliers of services had been put in place and left in place for so long.”
He says civil servants were forced to seek a consensus, which meant they could never make the most effective decisions in the public interest.
So how does he view the activity of lobby groups representing healthcare professionals? Drumm shies away from calling their behaviour unethical but says that lobbying in a less than honest way is wrong.
The former HSE boss firmly denies the then taoiseach, Bertie Ahern, put him under political pressure to ensure the new national children’s hospital was built on the campus of the Mater Misericordiae University Hospital in Ahern’s own constituency. “There were reports of clandestine meetings between the taoiseach and me. I can state that he never raised . . . the location of the new national children’s hospital with me.”
But he did have a fundamental disagreement with the government over its hospital colocation policy, which he hints could have triggered his resignation. “This issue led to a significant disagreement between a group comprising the minister, the secretary general of the [then] department of health and children, and the chairman of the board [of the HSE] on the one hand, and me on the other. I had to document for them my concern that a contract which allowed consultants unrestricted access to private practice in colocated private hospitals would essentially undermine our public hospital system.”
Salvation came in the form of the 80/20 rule, which, it was eventually agreed, would now apply to all consultant activity on the site – public and colocated private alike. Under the 80/20 clause in the latest consultant contract, agreed in 2008, consultants’ private caseload could provide up to 20 per cent of their clinical activity in public hospitals. Extending this to all clinical work in a co-located unit enabled the chief executive to support government policy.
Looking back to his time at the HSE, how did reality compare with expectation? “The biggest difference was realising how slow change would be . . . You think logical decisions, once accepted as strategy, will happen quickly because they are in the public interest.”
But back to Machiavelli's The Princeand the following words at the end of Drumm's book: "There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. Because the innovator has for enemies all those who have done well under the old conditions, and lukewarm defenders in those who may do well under the new. This coolness arises partly from fear of the opponents, who have the laws on their side, and partly from the incredulity of men who do not readily believe in new things until they have had a long experience of them."
Drumm offers his own warning after that of Machiavelli. “It is very difficult to reform a healthcare service if the public who pay for the service, and who will benefit from the changes, do not feel that they are in a position to insist on change from those of us who provide their frontline services.”
The Challenge of Change: putting patients before providersby Brendan Drumm is published by Orpen Press, €17.95
