Monday brought news that 25 full-time senior grade managers were appointed to the Health Service Executive in the second quarter of last year, far outstripping the recruitment of doctors and dentists.
Managers are needed, of course. But David Graeber in his academic tome of the same name labels many of the occupational roles in contemporary society "Bullshit Jobs". Jobs that are as meaningless as they are destructive. But the problem in the HSE is not management. It is managerialism.
Creeping managerialism is not peculiar to the health sector nor is it an Irish problem. It is an ideology based on a fundamental, if often unarticulated, belief that the public sector would work better if it used private sector management as an organising principle. It is pernicious and corrosive. It adopts the tools and concepts from the world of private sector and business, and excises all humanity from health and social care. It offers no return on the time and resources invested.
The HSE has been struggling for many years with demand outstripping supply of available services. This has led to overburdened emergency departments, hospital overcrowding and long delays in outpatient treatment. To counter these issues, managerialism offers KPIs – or key performance indicators to those lucky enough to be uninitiated.
The administrative burdens of managerialism are immense. The HSE uses an eye-watering array of KPIs. In relation to emergency alone, the proportion of people who wait less than six hours, nine hours and 24 hours to be treated from their time of registration as well as the proportion who leave without treatment must be monitored and reported monthly from each emergency department in the country. The turnaround time for ambulances must all be monitored and collated. And all of these statistics must also be reported separately for all those aged 75 and over. It is no wonder 381 full-time administrative posts were justified in the same round of HSE appointments.
‘Bullshit work’
This represents a veritable industry of meta data. Much more than “bullshit jobs”, this creates bullshit work. Administrators are completing audit trails and collating reports instead of managing appointment systems, ordering and updating equipment and progressing recruitment. No one denies the need for management and administrators. particularly at local level within the HSE, but they should act to support care work, not detract from it.
Administrators are completing audit trails and collating reports instead of managing appointment systems, ordering and updating equipment and progressing recruitment
And this is just the issue with KPIs. There is wide-ranging international evidence that the use of KPIs centres the work of any system to the indicator. In Irish emergency departments, a key performance indicator is the proportion of people who are treated and discharged within six hours of first registration. Those working within the system are motivated to ensure the largest possible number of cases clear emergency departments in six hours. On the other hand this has no impact on the very distressing reality faced by a much smaller group of people treated for days on trolleys in hospital corridors across the country. You get what you measure so to speak.
“Market testing” is a second important tool of managerialism. It was perhaps most famously used in the HSE to justify the appointment of the chief executive at his current salary level. It compares employees’ responsibilities and tasks in the public and private sector in order to assess pay and conditions. This process denies a central finding from organisational psychology. People within an organisation, particularly where there is a long service, compare their pay and conditions to each other. And perceived equity matters to morale. It takes only a brief check to realise that the 25 senior grade administrators appointed in the most recent reporting period will earn €70,000-€85,000 per annum. This is a salary well in excess of that commanded by staff nurses and non-consultant hospital doctors.
Demoralised by system
Added to this is evidence that auditing of KPIs creates tensions and difficulties in workplaces. Managers in central administration responsible for monitoring efficiency and accountability are often pitted against workers struggling to deliver care and services in an under-resourced environment. Healthcare workers come to believe that managers don’t understand the challenges they face and the work they do, and become demoralised by the system.
Healthcare workers come to believe that managers don't understand the challenges they face and the work they do
Ireland continues to have a relatively low number of doctors per head of population in the euro zone and the EU. We have approximately 3.4 doctors per 1,000 people compared to 5.5 in the euro area and 4.9 in the EU. Bloating of middle management is instantly recognisable to all of us who have spent long years in the public sector as a hallmark of a beleaguered system.
The first step to solving any problem is naming it. The long-standing issue within the HSE is managerialism. It is undermining services and commitment to services in all those working within it. There are now almost one million citizens on hospital waiting lists. We are in the middle of a pandemic. Our health service is creaking at the seams. Either we face up to this problem or something will give.
Orla Muldoon is professor of psychology at the University of Limerick