Health Managers need to watch the sea while others watch the waves

Denis Doherty
Denis Doherty

Having accepted the editor’s invitation to contribute an article to this special issue of Health Manager, I wondered what healthcare topics were attracting attention back in 1945, when what is now the HMI was founded? In my small collection of THE BELL magazine, I found there two articles of interest written by two well known doctors of that time.

One written by Dr. Gillman Moorhead in 1943 and titled HOSPITALS, FINANCE AND THE STATE dealt with the funding of voluntary hospitals in Dublin. Moorhead suggested that the hospitals had, to a large extent, lost the right to be called voluntary as a result of the introduction of ‘the Sweepstakes’ and the resulting control of expenditure by the Minister for Local Government & Public Health and the Hospital Commissioners. By way of example, Moorhead stated that in 1940, the ordinary expenditure of one Dublin hospital was £25,701, of which subscriptions accounted for only £161. He acknowledged that prior to ‘the Sweepstakes’ “many Dublin hospitals were not only ill equipped but were to some extent in bad repair”. Seventy-nine years on, the term voluntary hospital is still in use and still capable of being the focus of major controversy.

A year later, in1944, Dr. Earl McCarthy contributed an article titled EIRE’S SURPLUS DOCTORS in which he argued that “the large annual export of doctors from Eire to Great Britain presents a serious problem to our legislators, since the number of doctors we produce is out of all proportion to our needs”.

The proposed National Health Service was being hotly debated in Britain then and McCarthy held the view that the scheme held too many controversial and contested issues to justify prediction as to its effects on the emigrant Irish doctor.

There are similarities between times being experienced then and now in these islands. World War2 was impacting the quality of life on both islands and their economic futures were uncertain. Both islands are now emerging from a pandemic and dealing with the economic consequences of that and the war being waged by Russia in Ukraine.

Post 1945, the effects of the world war prompted creativity and innovation in relation to how public services were organised and funded; the introduction of the National Health Service being the most innovative in the health services area. Aneurin Bevan, who is generally viewed as the driving force in introducing the NHS, once claimed that, ‘if we could afford to pay our doctors, we wouldn’t need a National Health Service.’ Seventy-five years since it was introduced, the NHS remains untouchable and, some would say, unreformable.

Covid-19 produced many displays of the very high regard in which the NHS is held in Britain. In Ireland the displays of gratitude towards our health services have been much more muted even though Ireland has experienced fewer excess deaths attributable to Covid-19 relative to Britain and the vast majority of other European countries. Our health services played a very significant role in that success story but in a more ’taken for granted’ way than in many other countries. Our government too performed very well in managing Covid-19 but then scored a silly own goal by deciding that only some members of Health Team Ireland were eligible to receive the Covid reward payment. Team morale requires careful nurturing over time. One small-minded act can do untold harm.

In early May 2022 in Ireland, interviews with 400 healthcare staff, in relation to workplace issues during the early stages of the Covid-19 pandemic, obtained under Freedom of Information legislation, taken in isolation and without context received widespread media coverage. It reminded me of a view expressed by Donald Savoie, back in 1995, “In business, it does not matter if you get it wrong 10% of the time as long as you turn in a profit at the end of the year. In government, it does not matter if you get it right 90% of the time because the focus will be on the 10% of the time you get it wrong.”

Progressive organisations and enlightened managers know that controversy trumps success in gaining the attention of the media and political worlds

Progressive organisations and enlightened managers know that controversy trumps success in gaining the attention of the media and political worlds. They take a constructive approach and focus on how the learning that can be derived from negative experiences can be a catalyst for systemic improvements. Less adequate managers resort to self protection measures that often impact the 90% success figure more than the unsuccessful 10% one. 

Covid -19 and the current new demands on our economy will doubtless throw up many lessons, some of which will take many years to realise and others that are already becoming clear. The following examples are purely illustrative of what is already emerging:-

  • Our healthcare system does not have surge capacity to cater for seasonal demand, let alone major emergencies and pandemics.
  • We no longer have surplus doctors or other specialist staff and we do not value sufficiently all those whose contributions we rely upon.
  • Our system of annual budgeting and our failure to harmonise revenue and capital expenditure planning is not fit for purpose and inhibits meaningful workforce planning.
  • Our older people are often more vulnerable to shocks to our healthcare system than younger people.
  • Primary healthcare needs to be developed to serve as a vital, well-staffed and well equipped healthcare destination service.
  • Investment in technology enabled diagnostic and treatment support as well as management support systems needs to be greatly increased.
  • The cyber attack on the HSE IT systems makes the case for the level of security required in future.
  • There appears to be a case for a greater focus on the justification for continuing some services and some staffing roles and numbers.
  • Our private hospitals made a valuable contribution to hospital services provision while our public hospitals had to prioritise the care of Covid-19 patients.

The prize to be played for now is to apply the learning to be derived from the experience of Covid-19 and the economic consequences of the war in Ukraine.

In 2004, I was asked by a very senior figure in the interim HSE for my views on the policy formation approach the new organisation should adopt. I suggested it ought to be evidence based, costed and set out the human resources implications. To say that my suggestion went down like a lead balloon would be an understatement.

The approach I had been attempting to convey was that a very large, complex organisation, employing a knowledge workforce benefits from having a sharp focus on:-

  • Futures scanning: what George Bain described as watching the sea while others are watching the waves.
  • Workforce planning, development and management.
  • Financial planning and management.
  • Evidence based policy development and highly professional decision making when choices are required to align spending and service needs, often in an environment where needs exceed supply

The public health specialty is best suited to lead the multidisciplinary approach that is needed to undertake that responsibility. The new role Dr. Tony Holohan was earmarked to perform is a very important leadership one and needs to be progressed very soon, if Ireland is to remain prepared to cope with whatever seismic events the country may have to cope with in the years ahead, in addition to playing a key role in the planning and evaluation of our health services on an ongoing basis.

Peter Drucker, once described as the Einstein of management, described management as an art, a science and a profession. Healthcare management is a particularly complex and challenging form of management. We are fortunate in having in Ireland a mature and capable Health Management Institute keen to continue to contribute to meeting the challenges and opportunities our services will encounter in the years ahead.

Denis Doherty.

President, HMI 2007-2010

Principal, Denis Doherty &Associates, Healthcare Consultants

Former CEO, Midland & Mid Western Health Boards

Former Director, Office for Health Management

Former Director, Health Boards Executive