I would like to that you for the kind invitation to address you this evening. It is nearly a decade since the Institute of Leadership was established and in this time it has already established a reputation for the quality and importance of its work. By creating the Institute the College recognised that improving the capacity for leadership within health services is an essential part of achieving and sustaining the highest standards. With over 450 people registered on courses it is now one of the most important centres for developing clinical and other leadership skills.
In what is still a relatively short period the Institute has both played a positive role and helped to prove a wider point – that is that the influence of individual health professionals goes beyond their individual practices.
It is in the spirit of your work towards improving leadership in health that I would like to speak this evening. Were this a more political audience I might indulge myself in being a bit more partisan. After all, the government has been very helpful in recent weeks in providing things to talk about.
Instead of taking up the political issues of the day I would like to take a different approach and concentrate on the roles of both political and clinical leadership in the future of health provision and promotion.
When thinking back about crucial moments in the development of health services in Ireland the decade and a half after the Second World War stands out. What’s particularly interesting about it is how the popular memory of events omits a huge lesson in different approaches to leadership.
I admire Noel Browne. I think he had vision and showed real leadership in demanding that major worldwide advances in healthcare were made available to Irish people – especially to tackle TB. One could argue that he entered into some disputes in a way which made them impossible to win, but nonetheless as Minister for Health he was a clear force for good.
Because of the dramatic nature of Browne’s loss of office he has managed to overshadow what I think was the even more significant and effective leadership of the man who was both his predecessor and successor.
Dr James Ryan is not someone who is widely known, but he was a Minister of Health who achieved great things. His 1947 Health Act was the blueprint which Browne was trying to implement. It was a statement that the time had come for Ireland to significantly change and develop public health provision for its citizens. It was constrained by economic and social reality, but it was still bold and ambitious.
When Ryan returned to office following the fall of the government Browne served in, he kept up the broad agenda. There was a strategic retreat on one point, but long-term the scheme first envisaged by Ryan and then championed by Browne was implemented.
I find it very interesting that the two men did not see each other as rivals. On the contrary they had great mutual respect. A footnote to the Mother and Child controversy which is almost totally unnoticed is that Browne felt that Ryan did such a good job that he joined Ryan’s party and both of them sat together on the National Executive of Fianna Fáil for two years.
The most effective leadership is not always the leadership which gets the most notice.
A health system which helps people to maximise their health and quality of life should be a fundamental objective of any state. It is at the centre of the modern social contract. It is not a question of being a nanny state, but of being a decent society.
It is also very different from many other areas of public concern. It cannot be approached with fixed and unchanging views.
Modern health systems are highly complex and constantly evolving. They must respond to needs, opportunities and limits as they arise. Every person who qualifies as a health professional can be sure of only one thing about the course of their career – it will involve embracing change and the system will be completely different when they retire.
While the pace of change has slowed since the great breakthroughs of the early and mid-20th Century, it is still rapid and a constant theme is the growing interconnectedness of different services and specialisms.
Just like all historic professions, medicine was once the preserve of individuals working largely alone. After completing an apprenticeship a medical professional could practice without much concern for others. Even as hospitals and other large facilities developed the primacy of the individual was absolute.
Over the last half century this has become increasingly obsolete as a way of seeing healthcare. Many of the most important advances in treatment have involved working across disciplines – seeing links and building teams. This has also led to many of the biggest problems in terms of managing health systems and ensuring the full potential to help people is achieved.
In the planning and delivery of health services finding the right balance between specialist, stand-alone and coordinated activity is an issue in every country and within every institution. So too is the balance between investment in prevention and treatment.
The search for a single ‘answer’ to health challenges, for the magic bullet that will cure all our ills, can never work because it ignores the fundamental dynamism and complexity of health services which cater for the needs of both now and the future.
I believe that we are going through a period where the impact of financial pressures is being multiplied by a damaging idea of what it means to show leadership in health. The search for simple answers and memorable slogans is not only getting in the way of developing good practices it is undermining the chance to build on foundations which are stronger than has been acknowledged.
I have no doubt that strong leadership at political and clinical levels can deliver a significant advance in health outcomes. But in order to do this we must understand that nothing will be achieved through a gung-ho, ‘strong-man’ model of so-called tough, revolutionary leadership in health.
Real leadership in health has to respect a number of essential principles:
- It must start by acknowledging strengths where they exist;
- It must put aside the permanent revolution in favour of supporting a culture of reform and development;
- It must not let long-term benefits be lost in the search for short-term results;
- It must build leadership through the system and not just at the top;
- It must support world-class research for public health and not just industry; and crucially,
- It must challenge the political and administrative system to become more expert and more engaged in health policy.
I will take each of these in turn.
Respect strengths where they exist
It is the natural inclination of each generation of leaders to talk about how anything good only started when they took charge. Often the very last thing a new leader will do is to acknowledge existing strengths and past achievements. For far too many, the temptation is to present themselves as starting from scratch.
There are many problems with this which go beyond the cynicism of it.
One of the most consistent findings of research into factors for sustained growth and confidence in the public sector is the important of consistency over time.
For example, our highly competitive corporation tax has helped us to attract and retain investment but the rate itself was never enough. Other countries have often matched or beaten our rate. A key difference for us has been the building of a long-term trust that it is a policy which the Irish state is firmly committed to. The last thing an investor wants to hear from an Irish politician is that they have delivered the low rate – they want to hear that it’s been in place for a long time and the politician is determined to protect it.
Equally when you’re trying to attract or retain high class research, clinical or administrative talent it is much more effective to argue for a long-term commitment to an area than to promote the policy as solely contingent on new leadership.
The same type of principle applies in all sorts of sectors. People like challenges, they like the idea of being creative, but equally they are more likely to be attracted to areas where achievements are acknowledged and where there is a sustained and secure policy.
If I may make a more political point, albeit one which is very relevant, it is a much stronger economic case for Ireland to say that its recovery is based on the long-term strengths of its skills base and investment policies than the election-focused claims of the government. The case for leadership of recovery by our people rather than of our people also has the benefit of being true.
Except on limited occasions where an entirely new type of activity is needed, there is almost never a situation where there is nothing of value to be recognised – where there are no people whose work should be acknowledged and appreciated.
A leader who is trying to create a narrative of themselves coming to build in a barren wasteland is starting on a false premise and setting themselves up for at most short-term success.
This has great significance for the health sector.
It is easy to find fault with health provision today. It fails many people. It does not reach its potential in many areas. But it also delivers an immense amount of good for our society and has achieved great progress in the face of many difficulties.
You cannot improve health services if you fail to start by acknowledging that it has shown some real strengths over the years.
In the first decade of this century the number of acute cases dealt with by our hospitals increased by 55%. Just as importantly the quality and patient outcomes increased significantly as well. This was a step-change in performance. If you take this activity and public health initiatives together Ireland saw a concentrated increase in life expectancy and quality of life indicators. At a time when the population was rising at a rate well ahead of predictions and when expectations were also increasing, those working in our health services achieved remarkable things.
A system treating roughly 1½ million acute cases a year in a country of 4½ million and with rising patient outcomes is not one without merits – yet this is exactly the rhetoric which is heard from many politicians.
The denial of the achievements of the health system and its workforce is one of the many reasons for the slowly evolving crisis which we have seen in recent years. If you don’t recognise achievements how can you either protect or build on them? How can you motivate people to follow your leadership if you implicitly dismiss their past work?
I make no apologies for the fact that in different ministerial roles and as leader of my party I have regularly praised the work of Ireland’s public servants. The idea that they are a massively pampered class which does little for citizens is entirely false – and the prescription that the only way to get improvements and show leadership is to have conflict is nonsense.
I think real leadership is defined by having the strength to bring people with you; to argue for improvements based on respect for existing achievements and not allowing failings, of which there are always many, to define an entire system.
The Case for Reform and Development not Permanent Revolution
A closely related point, though still distinct, is the damage which can be cause by seeing leadership only in terms of someone pushing revolutionary change. The natural outcome of this is that every new leader believes that they must propose an upheaval if they are to get the reputation of being strong and in charge.
There are moments for revolutionary change in many areas and organisations, but the tendency to want to knock everything down before trying something new continues to cause immense damage.
The case of Irish Water jumps out in the past few years. There is zero basis to the idea that a single national semi-state organisation is the only way you can invest in improving the water system. There is an entirely different approach available – which is to invest in developing the existing system. Building formal arrangements across different council boundaries is something which has been done regularly within both the education and health systems. On basic things like the management of major emergencies and infrastructure development local authorities have repeatedly shown that they can deliver efficient investments on a regional basis. It is even possible to take this route and get much of the benefit of the accounting trick in relation the national debt which has given such an air of desperation to policy in the last two months.
But this alternative was dismissed because a ‘big bang’ approach was preferred. We have ended up with the worst of both worlds – a service which must be delivered by the existing bodies but which is directed by an organisation more interested in achieving institutional status than engaging with the public.
Because so much effort has been invested in proposing a so-called ‘visionary’ and revolutionary policy, the search for justification and the refusal to admit error has inevitably taken over. I hope that this lesson will be learnt in relation to similarly revolutionary changes which have been proposed for health funding.
A long term problem in relation to acute services has been that people cannot access many services fast enough. The capacity has not been there. There are two main choices, you can reform and invest in the current publicly-funded model or you can go for a more revolutionary change. The government has signed up for the later approach.
The White Paper on Universal Health Insurance is a genuinely revolutionary proposal. When it was published last year the government announced that it would ensure that every person would get treated when they needed treatment and it would cost no more than the current system. Put aside many of the obfuscations and you have a proposal which ends the guaranteed funding of any acute institution and would determine all funding by the ability to win contracts from private insurance companies. It is a very pure and simple market-based proposal.
It is also one which has immediate attraction for some politicians. It offers the chance to sell something with claims which cannot be tested before implementation.
Were this plan to be proceeded with it would lead to enormous upheaval and damage. We would end up with an Irish Water-type hybrid, where in order to keep things on the rails the current planning and funding system would be retained and run along-side the new bureaucracy. Contract uncertainty would threaten the ability to retain or attract staff. As the Dutch experience has shown, the initial inflated claims would soon be followed by inflated costs and falling quality.
This is a policy which looks good on a poster or in a speech, but we know in advance it will not work.
I don’t think that pushing a deeply flawed but revolutionary policy on a major problem is leadership – it’s more like short-term exploitation. Instead of simply delaying it for a year or so it should be abandoned.
Real leadership is to take the tougher approach of promoting a culture of reform and development – and to be willing to share in success.
I believe that the approach of the 2001 health Strategy was fundamentally sound. It was criticised by some at the time for proposing to build on the current funding model rather than to completely replace it – in fact it was in response to the Strategy that others produced the first health insurance proposals. However the scale of increased activity and outcomes under the strategy could not have been achieved any other way. A 55% increase in activity and a sustained rise in every other key indicator give the Strategy a very strong record to defend.
I believe that the debate on health policy has been distracted by the search for the dramatic alternative which will, to use the title of the very first universal health insurance policy document, “Cure Our Ills”.
After the upheaval of the last three years what is badly needed is clarity and commitment to a long-term and credible funding and oversight system. I believe that we need to say definitively that a core publicly-funded health system will continue. Only once we have this security can we then focus on tackling serious problems.
I think we need to enforce the principle that treatment in publicly-funded hospitals must be determined by clinical needs alone – there must be equality for all in our public system.
The contracting of private services is often a cost-effective and quality way of getting extra capacity, but the approach of funding a system through competitive private contracts is not an appropriate way of delivering the bulk of services.
The leadership the health system needs now is one which declares an end to the permanent revolution and instead shows a consistent commitment to reform and development.
Long-Term Improvements Must be Valued
Over recent years I’ve spoken at length in different fora about what I believe were the failings of practice and policy in the past – and how these contributed to making the crisis worse. One of these failings is that we do not value the long-term in our day-to-day debates on policy and politics.
In the field of crisis research it is a well-known idea that there is little credit given for preventing crises arising. This causes problems in most areas but in health it can be especially damaging.
Many of the biggest health challenges can only be tackled with policies which can take many years to have an impact. The more we know about the impact of long-term factors on health the more it becomes clear that a population health focus is needed. However the reality is that in only a few cases will a public health initiative show a major impact during the term of the political leader or manager responsible for it.
We all know that excessive alcohol consumption is one of the major causes of avoidable health problems in the Irish population. We also know that obesity is both causing trouble today and threatening an epidemic of obesity-related diseases in the future. Yet these are areas where it has proven very difficult to get any real engagement. Yes people are in-principle supportive of action – it’s just that it isn’t seen as that important.
The ban on smoking in the workplace is an exception which I think we should learn more from in terms of how it is possible to get on the agenda and be implemented successfully. After ten years we take it for granted, and many other countries have followed our example, but we forget that it was not inevitable. The smoking ban was not on any list of urgent political problems and it faced very significant opposition.
Ultimately it prevailed because of the strong political support which I received from colleagues, but also the willingness of groups within the health sector and the wider public to come in behind the ban. They were willing to respond to a call to put aside our normal agenda and stand together in the interests of an improvement in the long-term health of the Irish population.
Ten years on independent studies show that almost 4,000 lives have been saved and many more illnesses avoided.
In every part of our system we need to start encouraging more leadership on long-term issues. We need to respect and support efforts to identify measures which can tackle important issues and not just urgent ones.
This is an area where I think the Irish people are ahead of their leaders. They can see around them the impact of alcohol abuse and obesity. I believe that they would be supportive of a much more aggressive approach on these and other public health problems.
Leadership is not just from the Top
During my days as a history student an early and repeated lesson in historiography was that we should avoid the superficial attraction of the ‘great man’ theory of events. Personalities make events and forces more intelligible. They provide the opportunity for anecdotes and colour. They also often distract from a more complex range of contributors and factors which tell the real story.
This is not to dismiss the role of personalities – quite the opposite; there is no doubt that it’s difficult to achieve change without leadership from the top. However letting this focus dominate misses the dynamic of what works in practice.
I have no doubt that sustained change always requires each level of an organisation to assume its own leadership role. The idea of a single plan being pushed downwards for implementation does not reflect reality and it undermines the chance of actually achieving progress. This is especially true in health services.
Within each discipline and institution change requires a combination of local leadership and teamwork. The challenges faced at implementation level are always diverse and it is rare that a single approach will work everywhere. Only when there is local ownership of leading change can it happen.
For example, I believe that the greatest progress in the acute hospital system has been seen in those places where there has been a real commitment to the role of clinicians in management. They are better at budget planning and better at making sure that the potential of professionals is maximised.
One of the comments which was made in the main report on the handling of the run-up to the financial crisis is that within the civil service and regulatory agencies there was too much conformity. Not enough value was placed in challenging accepted wisdom. It was in fact believed that promotion of the general consensus was a positive in terms of both career success and institutional solidarity.
We have to find a way of showing people at all levels of our public services that their opinions are valued and that their initiative is welcomed. I’m absolutely not saying that public services can be run simply like private enterprise. Their objectives and their accountability mechanisms are completely different. Equally we have to value and support a public service ethic. However, the principle of respecting the role of individual and group leadership within the public sector is badly needed.
Support World-Class Research for both Industry and for Knowledge
As I mentioned earlier, long-term investment in the productive capacity of our country is the dominant reason why our economy is growing again. In fact the projections published yesterday by the European Commission are almost exactly the estimates for long-term growth potential published by the Commission and the OECD seven years ago.
It is the skills and application of the Irish people, developed over time and maintained in tough circumstances, which underpin our current and future prospects.
The sustained priority given to education over nearly five decades is the policy which deserves the most credit. If you look back at the first movements towards a commitment to education you do see a generation of extraordinary leaders and educationalists who worked together to make great things happen.
Very soon after he became Minister for Education in 1959 Patrick Hillery gave a remarkable speech to Dáil Éireann on the future of the education system. It was nominally on the matter of a one pound estimate to begin construction of UCD’s new campus is Belfield but Hillery used it as an opportunity to outline his and the government’s broader vision. In the face of arguments that a poor country couldn’t afford to educate professionals because they would just emigrate he said “If Ireland is to have a future it must have more education”.
Since then there has been a steady increase in educational attainment at every level of the system. There remain problems, particularly in catering for disadvantaged students and those with special educational needs, but Ireland has reached a level where our school completion and third-level qualification rates are well ahead of average.
The last phase of this is the push to develop a genuinely world-class capacity in research and innovation. As recently as 1997 the total dedicated research budget of the Department of Education was exactly zero. Since then there has been a dramatic change. A completely new infrastructure of research supports has been built. A long-term commitment to recruiting and supporting world-class researchers has delivered on every level of both impact and quality.
While these rankings are not always consistent, Irish researchers in immunology are now the most cited in the world – and they are 3rd in nanotechnology and 4th in computer science.
In areas where Ireland has built a strong research capacity it is also increasingly been successful in attracting investment and major job creation. Through the worst of the recession knowledge-intensive and export-orientated businesses continued to be successful. That is because Ireland had developed a leading edge.
It is a simple fact that every country which has sustained a high level of living standards since the Second World War invests significantly in research. Just as importantly they have invested in basic research.
Critical to Ireland’s research success in the last decade has been that it has had priorities but it has also allowed strengths to develop in other areas. Back in 1997 I secured government agreement to the principal that major research funding would be allocated by independent international competition alone. Quality would be allowed to prevail and research for knowledge would be respected. The educational system was challenged to deliver and it did.
I have always believed that the most important metric for research is the quality of the people trained within teams and by all measures universities and institutes have been incredibly successful in this.
What concerns me deeply is that there appears to have been a decisive move towards a much more controlling approach. The ability of research which is not immediately linked to industry to gain significant funding has been dramatically limited.
I know there have been reassurances given on the future of basic research funding, but these are only true if you throw out the accepted definition of what basic research is. I am told that even though we are, as I have said, ranked number one in the world for immunology research it is no longer being awarded the major funding that is needed to sustain this work.
One of the failed industrial policies of the past was what was known as the ‘advance factory mentality’ – the idea that what government had to do was to decide what type of facility to build and where to put it and everything would work out fine. In the same way, the more prescriptive we are in research funding the less effective it will be.
I am also worried that we will downplay areas which are low industrial priorities but could have a huge and positive impact on health and social issues. For example, immunology research offers potentially revolutionary impacts for many treatments and especially on reducing the swellings and infections which cause so much post-operative damage.
The last strategy for research and innovation was fully implemented, exceeded all targets and finished two years ago. It has been said in the Dáil that a new strategy is being prepared and will be published at an unknown time in the future. A bad start to the process is that there have been no consultations and no terms of reference have been published.
This may be a defining moment.
Investing in people, in the skills of our country, has helped us achieve real progress over fifty years. The leadership of an earlier generation needs to be renewed and not diverted away from an approach which has proven time and again that it works.
We Need Political Reform
Even though advanced research is of profound importance to the future of our country it has never been at the centre of a political debate. In the Oireachtas there are infrequent and respectful discussions about research a couple of times a year in committees. This reinforces the point that we simply do not have a political system which can provide the real leadership we need.
In the decade before our financial system effectively collapsed more time was spent by Dáil Éireann debating greyhound doping than debating financial regulation.
Three years ago the one unifying point between all parties was an acceptance that we do not have a political system which is fit for purpose. It is inherently short-term, it has little accountability, it does not have to ability to engage in many vital but technical discussions and it tends to follow events rather than lead them.
At the core of this is a model of governing which can best be described as democratic absolutism. We do get to choose our government, but once it is in office it has near total control.
Nearly every day the Taoiseach and his ministers respond to questions about policy by saying that once the government has decided what will happen the Dáil will be allowed to discuss it.
Not only has nothing of substance changed in recent years, you could say that we are going through a concerted period of greater centralisation of power. Vital decisions are getting less review, not more.
Once again the Irish Water debacle is a case in point. The legislation was rammed-through in four hours. Basic information was withheld. It took repeated effort over a lengthy period to get the picture of what was going one. And yet, three years after the policy was announced government has still not decided what it’s going to do.
I believe that we need a deep and broad reform of how government and parliament work in our country. We need them to be more expert and for there to be a meaningful giving up of power by the executive. Only once it can no longer control every part of the agenda, only when others have the resources to evaluate policy properly, will we get more soundly-based public policy.
There is actually a little-known provision of the Constitution which states that our parliament cannot even vote on many matters unless the Taoiseach agrees in advance that a vote can be held.
By having a model of political leadership which demands control, which prioritises big changes over harder work, which avoids the long term in favour of the immediate, which does not engage in detail, we end up with a parliament which is ever-more marginalised and a government which continues to stumble. We end up with slogans rather than more challenging visions.
“The best small country in the world to do business” is a good goal and a shared priority, but isn’t a vision for the future of a country. We need leadership which can be bolder, which can talk about being the best country in the world to grow old in, to receive treatment in, to be educated in.
We will never get this is we continue with the obsession with media spin and expanding central control.
Real leadership must start with having the strength to give up some power. To empower others to make a contribution and to understand that most great advances are a collective not a solo effort.