Minister for Health Simon Harris has promised on at least five occasions since his appointment to enforce measures to make health managers accountable for their actions.
The Minister appeared to ratchet up the pressure on HSE senior managers even further this week when he told the Fine Gael parliamentary party he intends to "shine a light on management".
Under pressure over lengthening waiting lists, he promised managers would be removed if they were not up to their jobs.
He is not the first minister in the department to point the finger at health management when a crisis erupts.
His predecessor Leo Varadkar promised "heads will roll" over hospital overcrowding but had to admit later he had no power to remove staff.
The reality is there is little the Minister, or anyone else, can do to punish under-performance when it occurs in the health service, just as there is little he can do to discipline managers when serious incidents occur.
The most that has happened in recent years is a game of musical chairs, where managers who have come under fire publicly have been moved around.
Ironically, some of those who were at the helm when major incidents occurred have been promoted.
Scandals
A look back at the recent history of the health service bears out this reality.
Two of the biggest scandals in the past decade were the death of Savita Halappanavar in University Hospital Galway (UHG) in 2012 and the succession of unnecessary and tragic baby deaths in Portlaoise hospital.
The chief executive of the Saolta hospital group, which includes UHG, at the time of Halappanavar's death, was Bill Maher.
Maher remained as head of Saolta until 2014, when he was sent to Dublin to manage the far larger RCSI hospital group.
While still in Galway, it emerged he had a business relationship with a UK company that secured contracts with Saolta worth nearly €340,000, and an official report found he should have declared this.
There is no evidence that HSE head office took any action, or even inquired, into this matter.
Maher subsequently moved to work in the private health sector.
Colette Cowan was the director of nursing in Saolta at the time of Halappanavar’s death.
Since then, she has been promoted to head of the University of Limerick Hospital Group, where current challenges include an ongoing outbreak of drug-resistant superbugs and massive trolley numbers.
Gerry O’Dwyer had regional responsibility for Portlaoise hospital, along with other hospitals in the midlands, between 2009 and 2013.
Three controversial infant deaths occurred in the hospital during this time.
He was later promoted to be interim group chief executive of the South-South West Hospital Group.
The point is not whether these managers or any other health service managerial staff members had any direct responsibility for what happened when they were in positions of authority.
Bad luck or multiple other factors may have been to blame. The problem is the system is not geared to examining the possibility of managerial failings.
Managerial chain
The single moment when Tony O’Brien has become most exercised during his five-year tenure as director general of the HSE came when the Health Information and Quality Authority planned to publish a report into Portlaoise that allocated blame for what happened right up the managerial chain.
An incensed Mr O’Brien vowed to injunct the draft report, a threat he later withdrew when the row became public.
After the report was published, the HSE agreed to set up an investigation into the responsibility of staff for what had occurred.
A report was promised within three months but after almost two years there is no sign of an end to the process and the parents of dead children are still waiting for accountability.
So while the doctors, nurses and midwives who treat patients are subject to professional disciplinary processes, often in public, no equivalent system exists to hold managers to account.
Arguably, though, the emphasis should be on rewarding good management, more than on punishing poor performance.
Many top managers are on salaries of €130,000-€140,000, which compare poorly with the private sector, given the size of the budgets they control and the high stakes involved.
There are no rewards, financial or otherwise, for good performance in a system that largely values caution over innovation.
Crisis
There are few high-quality managers seeking the privilege of being the scapegoat of the next minister for health when a crisis erupts.
In addition, the HSE is the victim of a long-term political paralysis that stifles innovation and reform at the top.
The process of structural reform has been put on hold for years.
Hospital groups were created, but most are semi-staffed, have no boards and no permanent chief executives. Neither has promised legislation to underpin their activities materialised.
All this points back to Harris, the man with the power to implement systemic change, should he decide to do so.
