Friction between Cork hospital and HSE region over staffing and spending goes back months

On Monday August 17th, the top executive at the largest hospital in the south of the country sent a warning letter to her superiors.

Within days, it had set off concerns and arguments within the Government and the health service about the impact on patient safety of staffing restrictions aimed at living within official budgets.

Jennifer Kearney, chief executive at Cork University Hospital (CUH), told the integrated healthcare area manager in the HSE South West region, Priscilla Lynch, that demand for services was outstripping the available workforce.

As winter approached, Kearney maintained, the situation was no longer sustainable.

She concluded her letter by quoting former US first lady Eleanor Roosevelt. “We must know what we think and speak out, even at the risk of unpopularity.”

Whatever about unpopularity, controversy quickly followed.

[ HSE executive instructed by Taoiseach and Minister’s offices to have ‘specific conversations’ with CUH bossOpens in new window ]

The letter leaked, causing consternation in both the higher echelons of the HSE as well as in Government, while consultants backed their chief executive.

Minister for Health Jennifer Carroll MacNeill strongly rebutted Kearney’s concerns. The hospital, she said, had hired more than any equivalent facility in the State and “by some margin”. She denied there were patient safety concerns due to staffing issues.

Kearney’s letter brought the issue to public attention, but background correspondence shows that staffing and financial overruns had been a source of friction for months. There were disputes between the hospital and regional management over the number of unfilled posts and on spending controls in a facility facing a €60 million deficit this year.

In April, Kearney had expressed deep unhappiness at how an internal meeting on financial controls had been handled, criticising the “presentation of predetermined outcomes”.

She said she and her team had been “subject to sustained and, at times, disproportionate criticism in relation to whole time equivalent (WTE) levels and the financial position”.

On April 29th, senior managers in HSE Southwest wrote in reply that it was “regrettable if the engagement was perceived as challenging, that was neither our intention nor perception of the engagement.

“Discussions of this nature – focused on performance, compliance with the approved WTE ceiling and financial sustainability – require direct and evidence-based scrutiny.”

On the same day, the head of HSE Southwest, Andy Philips, acknowledged in a note to Lynch that there were “significant tensions” between the region and clinical and management personnel in CUH.

These tensions can be seen in letters between hospital staff and regional management. From the hospital side there were repeated concerns raised about staffing and patient safety.

Management also had issues about CUH.

On July 30th, Lynch told Philips she was “gravely concerned by the recent recruitment decisions emanating from CUH”.

She pointed to “informal recruitment actions that do not comply with the recruitment code of practice to which the HSE must comply or risk losing its recruitment licence, nor do they comply with financial or funded workforce limits or most critically the direction of the CEO and you as [regional executive officer]”.

She maintained that “all local recruitment processes must cease in CUH to allow for oversight and appropriate governance”.

On the same day, Dr Maura Moriarty, consultant endocrinologist, wrote to Philips warning of a “serious and immediate patient safety risk” in the diabetes and endocrinology department as funding had not been approved for a locum to cover for a consultant taking leave.

“We anticipate a significant adverse impact on patients including delayed diagnosis and missed cancers, arising from disrupted outpatient clinics and unreviewed results, preventable, life-changing complications in patients whose conditions, particularly diabetes, require regular specialist review and increased emergency department attendances, as patients previously stable in outpatient care deteriorate without access to their usual specialist pathway,” she wrote.

On August 5th, Kearney warned the interventional radiology service could become unviable if a consultant took sick leave or was unavailable.

Ironically, the HSE region itself appeared to acknowledge there were critical staffing issues.

Philips had written to HSE chief executive Anne O’Connor on August 8th, saying he had paused about 700 posts on the register awaiting a decision on authorisation “pending further review of affordability”.

He set out posts that needed to be filled as a priority “to maintain [health watchdog] Hiqa registration, to prevent closure of beds, enable us to open surge to support the delivery of patient flow, discharge pathways and compliance obligations”.

Philips wrote: “As accountable officer, I need to bring to your attention the risks to patient safety within the anticipated winter pressures.”

His submission on the minimum number of positions the region needed included about 116 posts in services for older people, graduate nurses and healthcare assistants as well as consultant posts in interventional radiology, paediatric neurology and endocrinology. He said if the paediatric neurology post was not approved, the service in Cork would close to new children.

Meanwhile, HSE headquarters took issue with some of the content in Kearney’s letter of August 17th.

In August, acting chief executive Damien McCallion told Philips: “You need to reinforce the CUH CEO’s responsibility to ensure that patient safety risks and service delivery concerns are identified, assessed and mitigated with escalation through the hospital and regional governance structures in compliance with the HSE’s enterprise risk management policy.

“This is the responsibility of all senior leaders and cannot be abdicated through correspondence.”

McCallion argued there was “a significant number of inaccuracies” in Kearney’s letter including vacancy levels, safer staffing framework formula and numbers in CUH and the level of staffing growth.

McCallion also told Philips, in essence, that he needed to keep an eye over what was sent to Hiqa, which had sought a report about CUH on foot of the concerns raised by Kearney.