Susan Mitchell

Susan Mitchell, Health Editor, The Sunday Business Post

In November 2015, the Director-General of the HSE did an extensive interview with The Sunday Business Post in which he stated that the health service was suffering from the lack of a coherent vision or plan. Memorably, Tony O’Brien described the HSE as an “amorphous blob” that had been on death row for years. He said Ireland has “messed about with structures” in the absence of a coherent vision.  “We don’t have a single collective national understanding of what we want from healthcare,” he said. Mr O’Brien’s comments greatly annoyed the government at the time. Unfortunately, it is rare to see senior public servants say anything that might irritate their political masters, but it was hard for anyone to disagree with what he said. He initiated an important conversation.

Continuous Policy Change
The truth is that health service has been dogged by continuous policy change. After each election we begin the new electoral cycle where a new political administration introduces a raft of new policies. You don’t need to go back very many years in order to see this.  In 2010, the Fianna Fáil-led government was pursuing a policy of hospital co-location. There was a lengthy tender process and some consortia applied for planning permission. Then Fine Gael and Labour came to power. The co-location plan was axed. The Fine Gael/Labour coalition promised to deliver universal health insurance to all by 2016. A key report called Future Health set out the building blocks that we were told were required prior to the introduction of Universal Health Insurance. The government then established the stepping stones for UHI – hospital groups as a precursor to hospital trusts. The hospital groups are not functioning in the way that many hoped they would. The trusts were not established.

Unfortunately, the government did not do its homework on the cost of Universal Health Insurance. The plan for universal health insurance was dropped as the ESRI said the cost would be enormous. Last year, a group of cross-party TDs – the Committee on the Future of Healthcare – was tasked with developing a vision for the health service. Tony O’Brien’s comments and, indeed, efforts by the National Association of GPs and Roisín Shortall TD were germane to this. The Dáil Committee which was chaired by Roisín Shortall, produced a report called Slaintecare.

I’m not going to dwell on the contents of the report as Deputy Roisín Shortall, who is also on this panel and chaired the cross-party committee, can expand on the report’s proposals in more detail.

Perpetuating the Dysfunction
What I do want to focus on is whether there is any real appetite for meaningful reform of the health service in this country – and in particular amongst the key players and vested interests? The Midlands Regional Hospital in Portlaoise provides a good example. Portlaoise Hospital has been in the headlines for all the wrong reasons in recent years and, in some respects, it’s a microcosm of much that is wrong with the health service. In Portlaoise we see the following:

•  A lack of accountability

•  Political interference

•  Red flags being ignored

•  A failure to implement key recommendations made in major reports by the health regulator

•  A hospital that does not have the resources or the patient throughput to safely support some of the activity it is doing

•  Difficulties in recruiting and retaining key staff

These issues and problems are not unique to Portlaoise. They are perpetuating the dysfunction that is leading to poor access, long waiting lists and in some cases poor and mediocre outcomes. In January 2014, RTE’s Prime Time broadcast a programme about the tragic deaths of newborn babies in Portlaoise Hospital and the subsequent management of patients and their families by the hospital. Babies died. Mistakes were covered up. Parents were treated appallingly. Healthcare regulator HIQA was brought in to investigate.

Lack of Accountability
In its investigation report, HIQA did not identify or name those who had made serious mistakes. And mistakes were most certainly made. HIQA says it is legally precluded from doing so. There are no such limitations in the UK.  Yes, HIQA’s report was damning. Yes, it alluded to systemic problems and failures at “local, regional and national level”; but it failed to clearly identify which senior managers were directly involved in decision-making at key junctures. We still do not know.

In Ireland, regrettably, there appears to be no such thing as accountability. There are plenty of other examples of this lack of accountability.

Remember Aras Attracta? Here we saw residents being abused, slapped, kicked, and shouted at. Instead of hanging their heads in shame, some staff at this facility in Mayo went to the High Court with the support of their union, the Psychiatric Nurses Association (PNA) and secured injunctions against the HSE’s internal investigation.

At present the 100,000-plus health service employees are entitled to approve their own investigating team in HSE probes, even after a serious physical or sexual allegation of abuse has been made against them.  The HSE has said investigations regularly collapse and dismissals are rare. Staff under investigation are often out on full pay for years before they can eventually be dismissed. We continue to have a perverse situation where health service employees have the right to determine who investigates them. The HSE asked the Department to introduce legislation to tackle this. There’s no sign of any progress.

To what extent is this lack of accountability impacting the way in which services are being managed and indeed our soaring cost of legal claims. The State Claims Agency recently reported that our estimated liability for legal claims against the health service is now €1.67 billion – up 23 per cent on the previous year.

Emergency Medicine
But, back to Portlaoise. Portlaoise houses one of 29 publicly funded hospital emergency departments in this country. According to clinicians who work in emergency departments, we have far too many for a country of our size. That has been the official position of the Irish Association of Emergency Medicine (IAEM) since it issued a position paper on the subject in 2008. Emergency department staff must be able to access specialists in relevant specialties, including critical care, coronary care, as well as trauma and orthopaedic care to provide optimum treatment.

In its report, HIQA was very critical of the 24-hour emergency department at Portlaoise Hospital as it did not have the necessary resources. HIQA stated that the HSE itself had – in 2012 and 2013 – specifically identified clinical risks associated with emergency medicine. Importantly, HIQA pointed out that its own national recommendations about emergency care had been ignored in Portlaoise. This is exactly what I mean when I say reports are often ignored.

Political Interference
But what of political interference? Portlaoise Hospital was one of ten hospitals chosen by the HSE to have their 24/7 emergency department designation removed in 2011. The move never happened.

There was significant political interference, resulting in the HSE being forced to remove the hospital from the list.  The Dublin Midlands Hospital Group submitted a report to the Department of Health last summer in which it outlined a plan to replace the emergency department with a minor injuries unit. The report has been buried in the vortex that is the Department of Health.  So, here we are in 2017. And Portlaoise Hospital is still trying to provide a 24/7 emergency department. The reason for this is simple: political interference – and nothing less.

Portlaoise lies in a Fine Gael Minister’s constituency. Other politicians are equally resistant to change. They are condemning people to mediocrity. If you arrive at Portlaoise Hospital with a broken hip, doctors there will be unable to fix you. There are no orthopaedic surgeons working at the hospital.

If you arrive at Portlaoise Hospital with a heart attack and need a potentially life-saving stent to help unblock your artery, doctors there will be unable to do it. The hospital does not provide this service. Nor does it treat acute strokes. Portlaoise is not alone. There are similar deficits at emergency departments in other hospitals. This is not good for patient safety.  Much of the blame for this rests with our politicians. But health service management should perhaps stop bowing to political sensibilities. The public still wants hospitals to continue to be all things to all people, even though medics are specialising and sub-specialising. The reality is that we have too many acute hospitals. Replicating and staffing acute care rosters in so many centres across the country is expensive and wasteful.

We are struggling to staff these hospitals, a point that HIQA made about Portlaoise Hospital.  Recently, the HSE confirmed that 128 doctors who are currently working as consultants in publicly funded hospitals are not on the specialist register of the Medical Council. In other words, they have not completed specialist training even though they are employed as specialists. The HSE itself has said this posed “significant risk issues.”

The sad reality is that Ireland’s public health service is not regarded as an attractive place to work by many of our highly trained doctors.

Chronic Implementation Deficit Disorder
The remuneration on offer is lower than it is in most other English-speaking countries. The working conditions are regarded as poor. It can be difficult to access diagnostics. Secretarial or administrative support is often lacking. Many consultants have onerous on-call commitments. Surgeons regularly struggle to access operating theatres and maintain their skills. I have written many articles highlighting how some consultant posts that have been advertised have received no applicants whatsoever. We have one of the lowest numbers of physicians per 1,000 population in Europe. This is a real problem. It is negatively impacting waiting lists.

So, what is the system doing to address this?  I asked the head of one of our biggest medical representative bodies this very question yesterday.  I received a two-word response that was short and to the point. It began with an ‘F’ and ended with ‘All’. Unfortunately, she is right.

The government has decided to fight consultants looking for the money they were contractually promised in the 2008 contract. Hundreds of consultants have taken legal cases. Last year, The Irish Times reported that the Attorney-General had advised the state to settle these cases. Instead, we are going to the High Court. What kind of a message does it send to people we’re struggling to attract when the state dishonors its own commitments. Similarly, we want to move care out of hospitals and into the community, but many of our GPs are nearing retirement and we are not training enough. It is hard to see how we can ever hope to create a better health service without enough doctors.

The previous government asked DCU president Briain MacCraith to examine medical career structures. He made a series of proposals, many of which have not been implemented some three years later. The same can be said of so many other reports:

• The National Dementia Strategy
• The National Carers’ Strategy
• Reach Out, the national suicide strategy
• A Vision for Change
• The Value for Money review of Disability Services in Ireland.

The list goes on. And on.

Unfortunately our national propensity for aspirational report writing has been dwarfed by chronic implementation deficit disorder.  We have been talking about shifting care out of hospitals since Micheál Martin launched the then government’s primary care strategy called A New Direction in 2001.  Now, we have Slaintecare which also proposes shifting care away from hospitals.

Everyone agrees this makes sense. Take Chronic Obstructive Pulmonary Diseases – or COPD.

Our admission rate to hospitals for COPD is huge. It is a major contributor to the trolley crisis. Professor Tim McDonnell, the HSE’s lead for this, said there was a lack of resources in primary care to deal with this and so we have extraordinary admission rates.   There are plenty of other examples.

Whilst I think there are very many good things in the Slaintecare report, I share some of the concerns that have been expressed by former HSE chief, Brendan Drumm (around spending) and the HSE’s former surgical leader, Professor Frank Keane (existing structures).

Slaintecare calls for €3 billion in transitional and legacy funding to fund new primary care centres, diagnostics, hospital buildings and eHealth – an electronic health system – amongst other things.

Current Expenditure Extraordinarily High
There is no doubt that our capital spend has been woefully inadequate. We spent a fraction of our overall healthcare spend on capital projects – just €398 million in 2015.  Slaintecare also proposed a phased expansion in health and social care entitlements that would cost an additional €2.1 billion in current spending by the fifth year. We are already extraordinarily high spenders when it comes to current expenditure.

In 2015, our per capita spend was the third highest in Europe. OECD figures show that Ireland’s per capita spend was $5,275. Only the Germans and the Dutch spent more than we did.  The figures are all the more interesting as we have a comparatively young population. In 2015, 13 per cent of the Irish population was over 65 compared to an EU average of 19 per cent. The demand for healthcare increases as we age, so we should arguably be spending less. Where will that leave us as our population ages? In 2013, an OECD survey showed the cost of procedures in Irish public hospitals was the highest of all 26 countries surveyed.  The average cost for a knee replacement in Ireland was more than double what it was in Britain.

Is it fair to ask all of us to stump up so much more money, without a thorough examination of our existing cost base, or cost drivers? When talking about trying to improve the health service, I think it’s important to reference the challenges and obstacles that are often created by professional groups themselves.

Changing the System is a Painstaking Challenge
More doctors need to change the way they work. The failure to do this is exacerbating inefficiencies. Too many doctors are not doing a sufficient number of ward rounds. They are not seeing their patients often enough or planning their discharge early enough. Last time I checked, our national hospital discharge rate by 11 o’clock was about 10 per cent. Beds aren’t being freed up quickly enough.

The demarcation of professional roles is another serious problem. We are struggling to recruit theatre nurses at present and yet we cannot hire theatre assistants to plug that gap. Theatre assistants work very well in many other countries. The Irish Nurses and Midwives Organisation (INMO) is vehemently opposed to efforts to introduce theatre assistants.

In February 2016, the INMO secured the restoration of an allowance that would see nurses carry out tasks that are routinely done by nurses in other countries.

These tasks included:

• Inserting IV cannulas
• Taking bloods – or Phlebotomy
• Intravenous drug administration (first dose)
• Nurse led discharge

It was a good and practical reform, but doctors say it has hardly happened in some hospitals. Vision is clearly important, but changing the system is a painstaking, detailed operational challenge. Our inability to act on previous reports coupled with difficulties health service management faces in actually getting professionals to do things differently – does not auger well. We need a culture change.

Today Slaintecare really is the only show in town. The report has wisely proposed creating an implementation office under the auspices of the Taoiseach. This will be key. Will the Taoiseach be willing to take on this responsibility? If Taoiseach Leo Varadkar does not embrace this and take direct responsibility for it then I fear the Slaintecare report will also be relegated to a dusty shelf in the Department of Health.  Vision Without Implementation is just Hallucination.

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Additional Notes:

The most recent waiting list figures show we have 40,622 patients waiting longer than 6 months for daycase and inpatient care. That has increased from 10,765 in May 2012.

Our annual medicines bill tops €2 billion a year. We have one of the highest per capita spends on medicines (including pharmacy fees) in the OECD. Why is that? 

Much needs to be done to correct and improve the system we do have, but progress on this front is lamentably slow.  

That does not give grounds for much positivity. 

Are we, to quote Professor Frank Keane, “lumping a new healthcare strategy onto a dysfunctional and uncorrected system”, arguing that it was like oiling and rewinding a clock and expecting it to work better when its existing wheels and cogs didn’t fit properly.

Even, when you extrapolate what the OECD calls government funded/compulsory spend, you see that Ireland’s Exchequer funded spending on healthcare eclipses that of many other countries that offer better access to their health service and often better outcomes. 

In 2015, Ireland had 2.8 per 1,000 population. Austria had 5.1; Norway 4.4; Germany 4. Within the EU, only Poland had fewer doctors.

As a consequence, access to much of the health service is dreadful. There has been plenty of inaccurate political rhetoric suggesting that our waiting times have improved. It’s nonsense. They’re actually disimproving – a fact that is repeatedly borne out by official figures produced by the National Treatment Purchase Fund (NTPF). 

Our health outcomes are mediocre. Our survival rates for stomach, lung and colon cancer are significantly lower than they are in many other EU countries.

A more recent study by the OECD also concluded that our hospital costs – in other words the cost of procedures and operations – are very high.

A 2013 report showed that 56 per cent of patients admitted through emergency departments under surgeons did not require an operation. That raises some obvious questions around bed usage.

A certain proportion of this might be understandable, as some patients might need a scan or observation, but the figures clearly suggest that a large volume of unnecessary admissions were occurring.

Changing the system is a painstaking, detailed operational challenge that does not lend itself to the kind of big bold interventions beloved of politicians.