News Comment

Saturday 20 September 2014

Dan O'Brien: Varadkar will need guile, patience and persistence to improve Health

Money was thrown at the department up to 2008, proving that is only one factor in creating a good system, says Dan O'Brien

Published 24/08/2014 | 02:30

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‘We haven’t cracked the paradigm that it’s about the patient, not about the people working in the system’, said Tracey Cooper, former head of the Health Information and Quality Authority, earlier this year. Photo: Gareth Chaney Collins

The flow of health controversies is neverending. The role of the HSE in the latest abortion-related case and the premature departure of the top civil servant in the Department of Health were two charged issues over the past week alone.

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Criticisms of the healthcare system are constant and come from many quarters, but how bad is Ireland's healthcare system? And, as importantly, can the new Health Minister Leo Varadkar do much to improve it?

Let's start by saying that managing healthcare systems is extremely difficult given the extraordinary complexity of modern provision, as is to be seen in the frequency of controversy around the issue almost everywhere.

Across the water, no British health minister has stayed in the job for more than two years over the past decade and the NHS is rarely out of the news, almost always for the wrong reasons. In the US, few issues have caused as much division in recent times as the large scale reforms being rolled out and known as Obamacare. In the five continental countries in which I have lived, grumbling about experiences with doctors and hospitals is a staple of the national conversation in them all.

That health is such a hot political topic everywhere is not surprising. For most people, significant life events take place when interfacing with the system and most of these interactions are unpleasant by their nature. Often they are anguished and traumatic. When people feel - rightly or wrongly - that they have been let down by the system, anguish and trauma are all the greater and easily turn to anger and frustration.

But despite no shortage of such cases and the mostly negative media coverage of the health system, Irish people report themselves to be much healthier than people in most other rich countries. In 2011, 83pc of people surveyed described their health as good or very good, the fifth highest across the 34 countries of the OECD.

That sense of well-being is also reflected in how frequently we visit doctors' surgeries. Irish people have four consultations a year on average, compared to more than six across the OECD. Moreover, we are among the least likely in Europe to believe that our healthcare needs are unmet according to EU SILC surveys.

But none of this proves that Ireland's healthcare system is better than others. In fact, the (somewhat limited) available evidence points to the opposite conclusion. Most comparable healthcare outcomes show that despite improvements over time we still fare less well than our peers.

One in ten who are admitted to hospital after suffering a stroke die within a month, which is firmly on the bad end of the spectrum of OECD countries and twice the rate in Danish and American 
hospitals.

Nor is Ireland a good place to be diagnosed with cancer. Survivability rates for the three types of that awful illness available from the OECD are all below the average and, in the case of cervical cancer, far below the norm.

The area in which Ireland rates most poorly is in managing sepsis, a fact highly relevant in regards to the case of Tania McCabe in 2007 and Savita Halappanavar more recently. In no other country for which figures are available are the chances of dying from post-operative sepsis higher, according to the OECD data.

So is the wide-ranging underperformance for want of money? Although cutbacks in health spending have been among the biggest in Europe since 2009, these have reversed only a fraction of the increases in the previous decade when money was, almost literally, being thrown at the system.

Moreover, public health spending per person (adjusted to reflect local prices) is still around the OECD average and, in 2012, was higher than countries such as Finland and New Zealand.

Given this, and without downplaying the strains caused by financial constraints, the problem appears to be about much more than just money. Three broad 
issues account for the underperformance.

The first is politicisation. Although a hot potato everywhere, the politicisation of health is more intense in Ireland. No other country has independent parliamentarians who have unseated government TDs owing to highly localised health issues. If people prefer to have a bad hospital nearby instead of a better one further away, that is what they'll get, thanks to the country's near-unique electoral system.

The second explanation for the health system's underperformance is the power of vested interests. The reason medicines are unusually expensive in Ireland and public spending on them per person is among the highest in the OECD (despite a younger, and therefore healthier population) is because the industry is so important to the economy - its exports are equivalent to around one-third of GDP. Big pharma is famously ruthless in its lobbying the world over. With its unusually large clout in Ireland, it has been able to limit price reductions so that spending remains out of line with other countries.

Interests within the system - doctors, nurses and non-medical staff - also wield great clout. Their representatives are at least as powerful as in other countries, as evidenced by consultants and self-employed GPs having the highest incomes relative to average wages in the OECD in 2011 (the most recent figures available).

Honest insiders corroborate what the figures point to. "We haven't cracked the paradigm that it's about the patient, not about the people working in the system". These are the words of the then departing head of the Health Information and Quality Authority, Tracey Cooper, earlier this year.

The third cause of underperformance is poor management. Although bad management structures and practices are partially linked to the power of vested interests, in many cases it is more about inertia. The failure to roll out protocols on sepsis management consistently across the system years after they had been defined in the wake of Tania McCabe losing her life are a case in point.

Given the lack of additional money and the power of vested interests, it would seem that Varadkar's best chance of affecting change in the system is to squeeze out inertia and support the many people in the system who want to improve it and who have innovative ideas to achieve that end.

That requires greater delegation and freedom to manage for those tasked with running the system, extending the accountability guidelines being set down for civil servants to public health workers, better recruitment processes so that calibre of managers is improved and more training for clinicians who move into management positions.

It also means better data. No organisation can succeed without having good numbers and good systems of use numbers. This is especially true of large organisations and truer still for giant, complex organisations such as the HSE. Despite the centrality of good data, the Irish system has been much weaker on how it measures what it does than peer countries.

None of these measures is headline-grabbing, but for any minister for health, staying out of the headlines is usually as good as it gets. If Varadkar can slog away at improving the day-to-day management of the system it offers the best, and perhaps only real chance he has of improving outcomes.

Sunday Independent

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