Leading from the frontline

Healthcare reform cannot be imposed from above, but must be led from the frontline, writes Mr Jim Daly, IHCA CEO, ahead of the Association’s Annual Conference

In healthcare, as in any complex enterprise, real transformational change never happens by executive decree alone. It requires getting the foundations right and aligning strategy, clinical insight, and modern infrastructure behind a clear, unshakeable purpose.

At the IHCA, we believe clinical leadership is not the bottleneck in health reform, but the solution. The most effective healthcare systems are those driven by medical experience and on-the-ground governance. Yet for too long, the debate surrounding Irish healthcare has felt combative, with health service management on one side and senior medical professionals on the other. This has been all too evident in the recent demands to push hospital consultants onto weekend rosters without providing essential supporting staff, diagnostics, or bed capacity. That framing of ‘us’ and ‘them’ is profoundly unhelpful and it is patients who pay the ultimate price.

If we are to build a modern, world-class health service, we must move beyond division to constructive collaboration. But to lead effectively, our hospital consultants must be equipped with both the mandate and the tools to shape policy, direct care delivery, and safeguard the highest standards of clinical governance.

Transformation

The IHCA has undertaken a comprehensive transformation over the past year to ensure the Association serves as a current and credible advocate for senior medical specialists working in our hospitals, community, and mental health services. We recognise that supporting consultants in their clinical work requires supporting them as organisational leaders. Through the launch of our landmark Consultant Executive Leadership Programme earlier this year and the upcoming Consultant Education and Learning Institute in 2027, we are giving consultants the formal governance, managerial, and strategic skills needed to lead healthcare delivery into the future. This will be a personal benefit to them, but also a huge benefit to the wider health system.

Equally, our expert witness training initiative demonstrates how clinician-led education can directly support broader national legal and healthcare reform.

Behind the scenes the Association has completely modernised its administrative systems, enterprise tools, and digital platforms to ensure that our expanding membership receives agile, seamless support. And we are expanding our member benefits further, establishing a new Private Practice Network, and launching a dedicated IHCA podcast to ensure our consultants’ voices remain trusted, authoritative anchors in Irish public life.

Advocacy, however, must remain grounded in the daily realities of frontline clinical care. While the Association has welcomed a more constructive tone in higher-level dialogues with government officials, the HSE, and regional health leadership, a strong public voice remains indispensable when administrative proposals clash with the operational reality of our members on the ground.

Rostering

Again, I bring you back to the recent public reporting surrounding proposals for mandatory weekend rostering on Saturdays, irrespective of the rationale or patient benefit. Broadening access to services is a goal we share, but attempting to redistribute existing core hours into Saturdays without providing additional consultant workforce, multidisciplinary staffing, or diagnostic capacity is simply unworkable. Displacing Monday-to-Friday capacity to fill a weekend roster, without addressing the underlying capacity deficit, thins out the weekday care ‘blanket’, and jeopardises patient safety if replacement staffing is not available to fill the inevitable gaps during the rest of the week.

To reiterate, shifting a severely scarce clinical workforce from high-productivity Mondays to low-support Saturdays, where basic access to diagnostics, allied health, and community step-down beds is virtually non-existent, is, to paraphrase the Association’s President Prof Gabrielle Colleran, bordering on clinical and economic absurdity.

We all know that the health service would collapse overnight without the significant voluntary effort that consultants are already providing above and beyond their contracted hours. Indeed, recent IHCA surveys found that 41 per cent of consultants provide at least seven hours of uncompensated, discretionary work every single week.

We all know that the health service would collapse overnight without the significant voluntary effort that consultants are already providing above and beyond their contracted hours

We all want a functional six- or seven-day health service, but we must first provide the beds, the diagnostics, and the support staff required to run it. Forcing frontline clinicians into unworkable weekend schedules is a political distraction that treats patient safety as an afterthought.

Health regions

We had hoped that the old ‘command and control’ management of the health service was a thing of the past, as this has been shown to be incapable of reacting sufficiently to ensure the patient benefits. The opposite was evident during the height of the Covid-19 pandemic when authority was devolved to individual hospitals to re-organise, restructure, and re-configure services to great effect and with great efficiency.

The Association was hopeful that the creation of the HSE health regions would replicate the best of this localised agility. It was deeply regrettable, therefore, to witness the recent move to strip four HSE regions of their spending powers, reversing that previous move away from the centre. This retrograde step and the need for multi-annual budgeting in health will be discussed further at our Annual Conference by the Chief Economist at the Irish Fiscal Advisory Council Mr Niall Conroy.

Centralising decision-making does not always make sense. Take, for example, the recent decision to abolish all insourcing across the HSE. It is generally accepted that this has significantly contributed to the record number of people waiting for an appointment to be treated or assessed in public hospitals. Insourcing has been a very important mechanism to control waiting lists over the past decade. Stopping that safety valve without any alternative being in place will only result in more people being added to the waiting lists, which already topped the one million mark earlier this year.

All of this is why it is vital that decision-making authority is devolved from the overly centralised, bureaucratic centre to the local level. Indeed, the healthcare system needs to trust its senior clinicians to flexibly plan, run, and develop their own services. Examples of the excellence in innovation shown by consultants up and down the country will be showcased at the Association’s upcoming Annual Conference in Kilkenny. Such clinician-led governance and innovation at hospital and system level is key to ensuring that both productivity and patient care become the twin pillars of our future success.

Regional executive officers should be similarly supported if they put patient welfare ahead of administrative compliance with embargoes on medical staff that are already funded.

It is unacceptable that internal HSE administrative bottlenecks can override agreed and approved consultant appointments and force existing staff to try to maintain increasingly fragile services in the face of ever-increasing demand for hospital care. The Association is delighted to have Cork University CEO Ms Jennifer Kearney speaking at this year’s meeting, together with HSE CEO Ms Anne O’Connor.

Partnership

As we look ahead to our Annual Conference, members of the IHCA are gathering from a position of renewed organisational strength. Our message to health service managers, policymakers, and government leadership is clear: Consultants do not seek to be feared or revered, but to be respected as essential partners advocating for patients. But we need to be listened to and engaged with if solutions for our ailing health service are to be found.

However, healthcare reform cannot be designed in a silo and imposed on crowded hospital wards. It must be built collaboratively, drawing upon the frontline expertise of the consultant and other medical staff who deliver care every single day to thousands of our population.

By placing clinical leaders at the very heart of health policy, governance, and system design, we can finally move from frustration to progress and deliver a safer, fairer, and more responsive health service for the entire nation. The IHCA stands ready to support and assist health service management in that process, as we know it will dramatically improve patient care.

Consultants can register to attend the Annual Conference by visiting www.ihca.ie.