Minister in the spotlight as health controversies intensify

'It is frightening, what was happening at CHI',
Sinn Féin
health spokesman
David Cullinane
said as politician after politician at the Oireachtas health committee tore strips off the embattled group that runs children's hospital services in Dublin.
The hospital group knew it would be facing a rough day given the litany of contentious issues facing it: the
implantation of unauthorised springs
, allegations surrounding
unnecessary hip operations
, controversy over lengthy waiting lists for spinal surgery, an internal report identifying dysfunctional behaviour and a
toxic culture in parts of CHI
as well as concerns over whether
National Treatment Purchase Fund
(NTPF) money earmarked for reducing hospital waiting lists had been misused.
As CHI was heading to the bear pit that is the committee room on Thursday, Minister for Health
Jennifer Carroll MacNeill
was on her way to a European health council meeting in Luxembourg. But she and her officials were keeping a close eye on proceedings as the Oireachtas committee heard directly from those running CHI for the first time.
'There is absolutely zero confidence in the CHI board, zero confidence in the management,' said Fianna Fáil TD Martin Daly.
READ MORE
He later maintained he was reflecting the feelings of colleagues in the Oireachtas.
On the ministerial corridors at Leinster House, senior figures may not be frightened by events at CHI. But there is no doubt there are strong concerns that after five years of relative quiet – accompanied by unprecedented levels of investment – health scandals are once again dominating the agenda.
How all this is handled will be a big test for Carroll MacNeill in her first term as a senior Minister.
Initially she was seen as one of the better performers in the Cabinet. But a number of figures in Government point out that in recent weeks things seem to be boiling over on a number of fronts.
There is a clear sense within Government that the aggregate effect of the series of controversies represents an important moment and a shift in gears for Carroll MacNeill's ministerial career.
'It is a huge test for her, a huge challenge,' one source said, adding there were nascent concerns about keeping the centre of Government informed as the controversies develop.
'While she is the line minister, she is responsible, from a public perception point of view, the Government is responsible.'
She must also master the inner workings and unpredictable dynamics of a health crisis – something that eventually falls to everyone in her position. This is particularly the case for one that is, in fact, composed of several overlapping sub-crises – a 'sprawling controversy with so many elements', as one source described it.
She must keep track of timelines, keep the information flow running, keep across who knew what and when. For a first-time Cabinet minister, it is the ultimate acid test.
Some of this may just be timing. The report by the health services watchdog, the
Health Information and Quality Authority
(Hiqa) on the unauthorised springs was always set for May and Government knew this would probably cause a storm that would be quickly followed by an equally damaging analysis into operations for children with developmental dysplasia of the hip.
However, the stunning leak of an internal CHI report identifying potential patient safety risks, questionable use of NTPF-funded waiting list clinics and a toxic culture at one CHI hospital came out of left field.
Ministers and health chiefs said they had been blindsided. The revelations also highlighted divisions between different parts of the health system and put the spotlight on flaws in the governance structures.
Last week
the NTPF confirmed it had suspended funding for waiting list initiatives
at another centre, Beaumont Hospital in Dublin, on foot of potential financial irregularities.
The Irish Times revealed this followed a letter sent to the chairwoman of Beaumont by consultants in which they maintained the hospital had billed the NTPF for about 1,400 patients treated in their regular public clinic.
The Department of Health – and presumably the Minister – had been aware of this development since April. Carroll MacNeill had directed the HSE to send internal auditors into
Beaumont
.
However, the public was not told until June 11th.
Some highly placed sources maintain all this has led to concerns about the information flow around Government.
One Minister told The Irish Times there had been discussions about what was coming out.
'As we hear things, things are being circulated,' they said.
'There is no concern about the political messaging, but there is huge concern about what we hear is going on – everything, from what you hear about [HSE chief]
Bernard Gloster bringing in the gardaí
to everything that is going on in terms of governance, the whole shooting match. But the primary concern is about the children.'
Another Government figure said there is real concern that health may blow up (politically) in a way that it has not done in five years and that there may be too much of a hands-off approach by the Minister.
The Government is only too aware there is more drama to come.
CHI, the HSE and the NTPF will be before the Dáil Public Accounts Committee in early July.
An external review into paediatric orthopaedic surgery being carried out for the HSE is also still awaited.
A separate HSE report on 'insourcing', where some staff formed private companies to carry out additional work outside regular hours to tackle waiting lists, is also due, as are the findings of the internal auditors sent into Beaumont.
Governments have spent more than €1.6 billion on waiting lists over recent years, using the NTPF, the HSE 'insourcing' and other arrangements. Any questionable findings will undoubtedly lead to more allegations about waste.
Carroll MacNeill is facing a balancing act of trying to deal with serious issues in CHI at a time when the organisation should, ideally, be concentrating on moving the three existing paediatric centres in Dublin into the new €2.4 billion national children's hospital.
TDs, like Daly, may have no confidence in CHI. But in the meantime services for children have to continue and workforce planning and other arrangements for the move have to be carried out in parallel.
In late May the Minister told the Dáil: 'I am trying to look at this question in relation to the broader governance of CHI in a way that enables the functional continuity of CHI, both to respond to the various patient needs and ... the broader running of the paediatric system and to move us towards opening the new hospital. I want to ensure we see the appropriate governance structure in place to make sure that we have clinical leads who are managing each team.'
However, within Government the ghost of the 2018 cervical check scandal casts a long shadow. This centred on retrospective audits of cervical cancer screenings that showed that 221 women's smear test readings missed abnormalities, leading to the development of cervical cancer. The results were not disclosed to 162 women and a number subsequently died.
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The fallout caused a national outcry. Ministers, doctors and health administrators did not adequately argue their own case and in the face of relentless criticism, a narrative took root and proved difficult to eradicate.
There are fears that further revelations at the Public Accounts Committee or in forthcoming reports could spark further controversy.
A number of sources have voiced concerns that the health service and CHI could replicate the rolling controversy seen over the RTÉ payments scandal two summers ago.
The gaps and governance flaws identified by the CHI controversy also leaves the Minister with a decision on whether further reforms are needed.
Health economist at UCC Dr Brian Turner described the current system as a complex mix of public and private funding and delivery with a large degree of overlap.
He said there were publicly-funded public hospitals (run by the HSE), publicly-funded voluntary hospitals (run by their own boards) and public patients in private facilities such as nursing homes. In addition, the NTPF buys treatment in both the public and private systems.
On top of this HSE reforms introduced last year led to new regional chief executives appointed to oversee services in geographic areas that covered both public and voluntary hospitals.
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One obvious question from this is who does the chief executive in a voluntary hospital primarily report to? Is it to the hospital board or the HSE regional chief executive?
Such questions are not purely academic.
At the Oireachtas committee, it became clear CHI did not believe its internal report merited a referral to the Garda. The HSE, on the other hand, wanted gardaí involved.
One experienced health service figure told The Irish Times the CHI issue was casting a spotlight on the key governance question: who is in charge of what in the health service?
With some exceptions, most of the main academic teaching hospitals covering most of the main specialities are in the voluntary sector. The staff are considered to be public servants but the hospitals are run by their own boards.
Voluntary hospitals tend to jealously guard their independence.
One senior figure pointed to a row last year when former minister for health
Stephen Donnelly
wanted all hospitals to adopt a new system that would provide greater visibility over productivity. A number of voluntary hospitals objected until the minster threatened to withhold capital funding.
CHI reported to the minister, not to the HSE. However, when Donnelly wanted a new chief executive appointed as the former chief executive Eilish Hardiman had served the maximum two terms under Government policy, the CHI board disagreed.
Simon Harris
, as minister for health in 2017 established a review of the role of voluntary organisations in the operation of the health sector. But many key structures remained in place.
One senior health source said voluntary hospitals previously argued they provided a set level of services for the State under an agreement each year but were subsequently free to treat fee-paying patients and do other work.
However, private practice in public hospitals is now to be eliminated over time under
Sláintecare
, the long-term plan to achieve universal, single-tier health and social care.
One experienced health figure said it was widely known that the governance arrangements were flawed. However, he questioned whether the Government had the bandwidth or determination to deal with the aggravation that would flow from trying to change the current model of care – a process that could take several years, and possibly beyond the next general election.

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