How we should be managing the HSE

If you can get people excited about selling Heinz beans or Coca Cola, you, sure as hell can get them excited about delivering high quality health care, Sir Gerry Robinson tells Maureen Browne.

The essence of running any large organisation, such as the HSE successfully, is leadership skills, complete clarity about what you want to achieve over a six to seven year period and how you plan to achieve it, according to management guru, Sir Gerry Robinson.

“Leadership skills are the single most important requirement. You must make people excited about being part of it. You need to give them responsibility for certain targets and then hold them accountable for achieving these.

“It shouldn’t be hard to get people working in the HSE believing in the importance of what they do. If you can get people excited about selling Heinz beans or Coca Cola, you, sure as hell can get them excited about delivering high quality health care.

“The leader must have the capacity to really get people on board right across the system. They must feel that they have to do a decent job and when they do, they must be told how brilliant they are.

“You must also have real clarity about what is meant by success and what achievements will mean success and I doubt if that has been done for the HSE. You need to set up a raft of objectives which you will achieve over a six to seven year period. Objectives could be on the lines of having the lowest waiting lists in Europe or perhaps the best cancer cure rates. From these will come a plan for the way you structure the organisation, the people you need, the hospital specialties and how you manage the system.

An awful middle ground
“There are decent enough statistics to tell you where the bulk of your problems are and you start to work your way logically towards your targets, training and deploying staff but you cannot do that without a clear plan”

He sees the management of the HSE as a strange and awful middle ground between a service which is always going to be a political hot potato and which is also terribly subtle and can easily be put off track by one story.

“For example a story about an unfortunate patient who doesn’t get an operation and dies will result in enormous publicity and it’s very difficult to separate the publicity from the reality of what you are trying to do. You are dealing with a highly intelligent group of people who know how to manipulate situations. It’s difficult and perhaps even to a great extent, impossible within a political system.

You must make people excited about being part of something important, you must give them responsibility for certain targets and then hold them accountable for achieving these

“I don’t know anything about the HSE but it’s probably fairly similar to the NHS, on a smaller scale. It’s an enormous employer and in most organisations a CEO requires a period of at least a year when you question everything. Find out the situation, be prepared to take on people and question what they do. This provides a long period for people to get stories out that this is going to be cut and that’s going to be done and during this period, political interference is almost guaranteed.

Putting on the tin helmet
“You need somebody capable of going in there, putting on the tin helmet and insisting they get three to four years when they are left alone to make decisions that need to be made and, of course, not all of these will be well received within the HSE itself.

“While I accept that all the publicity may not reflect real problems within the HSE, there clearly are real difficulties.

“To be CEO of the HSE is a very hard managerial task but a managerial task is what it is. It has nothing to do with a medical background – it’s about managing the largest employer and probably the most complex organisation in the country.

“It is by far the largest spending agency and to run it well, efficiently and economically is a huge task. To do it you need to be able to attract the very best people. To get a CEO, you might get away with tapping somebody on the shoulder who has made their wealth elsewhere but that limits the search. You need a youngish successful manager who’s prepared to get old quickly.

You need somebody capable of going in there putting on the tin helmet and insisting they get three to four years when they are left alone to make the decisions that need to be made without political interference.

“I think that the HSE needs to be able to pay the kind of salaries paid in the international field and I’m talking about millions rather than hundreds of thousands. Oh, I realise the press would go bananas but so what. The whole furore would pale into insignificance very quickly if the result was that you got a CEO who made the service work brilliantly.

Nerves of steel
“It would also put on an enormous amount of pressure to make absolutely sure the person who gets the job has a proven track record, nerves of steel and is known to have done it before.

Commenting on the joint HMI/UL study which revealed that health services managers felt HSE Corporate was a very centralised organisation operating by command and control, whereas there was a perception that local management was much more participative and appreciate of the work of staff, he said he thought the central staff of the HSE should be as small as humanly possible.

“There shouldn’t be a raft of people at the centre, second guessing those in the field. It can’t be difficult to split it into a number of regions with a clear reporting structure, regular follow ups against objectives and comparisons with other regions. If something is working in one region why not in another?

You need a youngish successful manager who’s prepared to get old quickly

“In the NHS there is a raft of people at the centre and then another raft of people in the Department of Health, all collecting information, laying down regulations and second guessing one another.

“To eliminate all that you have to have a very small team at the centre, say about 70 – 80 people and very clear rules and regulations. Part of the problem of having lots of people is that when something goes wrong you can’t pin it on anyone. When held accountable for failure and recognised for success, people perform at their best. Recognition of something well done is vital if people are to be motivated about what they do.

Six key people
“One of the first things you do in companies which are badly run is to see how clearly the structure is delineated; do people know who’s responsible for what. It’s not difficult to correct, you get five to six key people together to hammer out the key issues, who is responsible for what, who will be held accountable and how review procedures work.

“Then you meet every month to go through everything, see what has been done and follow up – if you have to ask people a third time why something hasn’t been done, you need to tell them that you don’t want to ask them again.

“Every organisation should have clear accountability across the system. Everyone wants to know exactly who they report to. Straightforward accountability is the key to any organisation.

Robinson is amazed at the findings from the HMI/UL survey that over half senior managers had no budgets while 19 per cent had budgets of €10 million or over. “You can’t have a lack of clarity. For example where your budget is concerned, you must know how it is split up, who has responsibility for spending it and making sure it is spent wisely and properly.”

I would absolutely insist people were only promoted on the basis of their achievements

“People tend to think organisations only work against the profit motive. That’s tosh, they work against any set of clearly laid out objectives. More often than not, it’s all a bit dull, you’re checking what has been done, repeating where you need to go, checking repeating, checking repeating.

“Management is about setting things out in a clear way and logically following through to see that it happens. Somebody once said that by the time you are absolutely sick to death of saying something, people are just beginning to cop on to it.”

Loyalty to profession
Queried on the best way to manage an organisation with a multitude of professions where loyalty to the profession could take precedence over loyalty to the organisation, he said that by and large people with medical qualifications in the HSE are in it for the right reasons and managers should be excited about their professionalism. “I don’t think it’s a problem. If your starting point is to beat up medics, you are the wrong person. People who should be most committed to the HSE are those who are at the front line doing their stuff. Everything else is subservient. In the HSE, you are dealing with sharp intelligent people and they have to feel valued and motivated. They have to feel they are supported by the best people possible, that their time is well planned. Running the health services is about getting medical professionals in front of patients as simply and as effectively as possible, leaving the medical side in their hands and arranging the follow up as efficiently as possible. That is about decent systems in place.”

Robinson is no fan of a hospital structure where the CEO’s first duty is to a hospital board rather than the HSE which supplies the hospital funding.

“I would introduce a rule which says that irrespective of the Board, where a hospital is funded by the HSE, the CEO is first and foremost responsible to the HSE. There could be a five year or longer phasing in period. I understand the history attached to the Irish voluntary hospitals but I don’t think if it is properly managed it is beyond sensible people to sort this out. There may be blow ups, but I think the organisation which pays the money must have the control. Hospitals which are funded by the HSE must comply with the same rules regardless of their ownership.”

He is not too impressed either with vast amounts of report and information gathering.

“When you start analysing it, you nearly always find that the majority of information collated doesn’t change a damn thing. You would need a root and branch look at the purpose of all this information – is it just to collect statistics? Is it to answer Dail questions? Is it about collecting genuine information to improve the services?”

He thinks it right that the HSE CEO should have the final say in what happens not the politicians. Their role is to set the objectives, arrange the finance and leave the running to the HSE.

Does he have any advice for the new HSE CEO? “Yes, I do. If there is one thing I could change in the NHS – and it is probably better here – I would absolutely insist people were only promoted on the basis of their achievements. In these organisations, people are brilliant at playing upwards and get promoted but they do very little here because it’s risky.”