It is difficult to imagine what the health services in Ireland must have been like in 1917 when the Irish Hospitals Registrars Association was established. It was representative of the Registrars/Secretaries of the Dublin Voluntary Hospitals. The Easter Rising had occurred the previous year, World War 1 was raging and the partition of Ireland was only a few years away. Great credit is owed to those who showed foresight and tenacity in establishing the Association in the very difficult times that were in it.
In 1945, the year World War 2 ended, the Institute of Hospital Administrators was established. The economy was weak and economic forecasts were bleak. On the healthcare front though, some game-changing discoveries had recently occurred, most notably penicillin and streptomycin.
The origins of the health services we have today can be traced back to the Health Act of 1947. The emphasis was placed on simplifying and rationalising services entitlement and services delivery. The Health Acts of 1947 and 1953 resulted in the county councils, as health authorities, becoming responsible for delivering health services other than mental health services.
In relation to the management of our health services, a key development was the introduction of county and city managers in the early nineteen forties. These were statutory offices. The functions of the local authorities were categorised as either reserved, meaning they were performed by the elected members, or executive, meaning they were performed by the county or city manager. County and city managers were obliged to have regard to the policies of their councils in their decision-making. This was a radical and progressive initiative that resembled more the way public services were organised, managed and delivered in the United States than how they were organised, managed and delivered in the United Kingdom. Managers could delegate their statutory functions to other officers of the Council.
Prior to the introduction of County and City Managers, the terms manager and management did not feature in the vocabulary of how health services were organized, managed and delivered in Ireland. Words like Administrator or Secretary were used to describe the most senior non-clinical positions in hospitals.
By the mid nineteen sixties radical change was in the air. The outcome was a White Paper in 1966 followed by a Health Act in 1970. The changes were indeed radical. They were overdue. They replaced the ‘Poor Relief’ legislation dating from 1838 that was still in force more than a century on.
In keeping with the winds of change being experienced, the Institute was renamed the HMI (Health Management Institute). It remains as relevant now as it was back then.
Eight health boards came into existence in 1971.The composition of health boards was admirable, in the democratic sense. Each board was composed of elected members from the counties comprising the health board area and elected members of the health care professions, plus a small number of Ministerial nominees. In practice the view ‘that all politics are local’ was borne out. A proposed oversight body that would have a role in relation to where healthcare facilities, hospitals for example, would be distributed was not implemented.
The Fitzgerald Report, that advised on the number and location of acute hospitals, proved to be a political hot potato. Only the less contentious recommendations in relation to the location of hospitals were implemented. A review that invented the notion of ‘minimum scale hospital’ was accepted. That approach produced a short-term political solution but contributed to a much longer-term acute care delivery problem.
The jobs of health board members and managers were made very difficult by the policy deficit in relation to the configuration of services. The IPA and the HMI performed valuable roles in developing the managerial skills required in the challenging political and service delivery environments then existing.
In 1994, the health strategy titled “Shaping a Healthier Future” was published. It was a remarkably farsighted and enlightened document. It recommended that the health services should be structured so as to achieve health and social gains for the users of our services. Michael Kelly, the Secretary General of the Department of Health, performed the key leadership role in the formation and implementation of the strategy. Implementation projects were resourced, implemented and secured strong support throughout the services. To mention just two successful projects that were at advanced stages of development, one related to the introduction of a personal development planning approach to staff development and retention and the other on the use of classical project planning customised to the healthcare environment.
Then, the government decided to introduce major change. A new entity, to be known as the HSE (Health Services Executive), would be responsible for the delivery of all statutory and non-statutory health services. An interim Executive Chairperson and support executives were engaged. A management style very different to that then prevalent in our health services and indeed in the health services more generally across the EU was experienced.
Projects in development were discontinued and the staff members were reassigned to other work.
We will never know if a HR approach that valued and supported a personal development planning approach would have resulted in improved recruitment and retention of staff to the extent that the evidence supportive of that approach suggested it would. Evidence of success would have been a more stable workforce, less reliance on agency staff, cost savings and improved patient/staff continuity.
Classical project management, validated to a healthcare environment, had been demonstrated to have great potential. Transition from a distributed delivery system to a centralised one benefits from standard approaches to time, cost, employee and community engagement.
With the benefit of hindsight, I believe that the difficult transition from a distributed to a centralised delivery system has impacted negatively on the results that the able and committed CEOs of the HSE have been able to achieve.
Had the HMI not existed twenty years ago, one would have had to be invented to provide a place where independent, progressive thinking in relation to healthcare management and thinking is valued and supported. Long may it continue to prosper.
References:
HMI Origins. Edward (Ned Byrne) Health Manager, June 2022
The Health Services of Ireland, Brendan Hensey
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