Saturday 7 December 2019

Reform has become a matter of life and death

The fact that we can't rely on the health service shows that the public sector needs urgent reform, writes Brendan O'Connor

Let's, as they say in Tallaght Hospital, put the X-rays aside for the moment. Referral letters from GPs to hospitals are, as Muiris Houston put it on Friday, at the core of our health system. The way it works is quite simple. If your GP is worried that there may be something seriously wrong with you, they will refer you to a specialist. The GP will write a letter outlining their concerns, your symptoms, possibly including information you have not even been told yourself. Said letter, a fairly urgent letter you would imagine, is then sent to the hospital, and the idea is that you would get the consultation you urgently need as soon as possible.

In Tallaght Hospital a review discovered that such a letter goes through 20 stages before it results in a consultation. We now know that many of these urgent letters weren't even being opened. These were potentially matters of life and death, certainly, in many cases, of serious illness, and they were just being ignored.

To any of us who work in a normal business environment, even in areas far more trivial than the life-and-death matters dealt with by medics, the notion of thousands of letters piling up unopened is quite simply surreal. You even find yourself trying to visualise it. Were these thousands of letters piled up in a room somewhere? And were more and more of them dumped in there in wheelbarrows as they came in? And did everyone agree just to ignore these ticking time bombs, to never mention it as they walked around on a carpet that bulged with the urgent realities that had been swept under it?

And the only reason it was noticed is because doctors who were writing letters on behalf of patients were simply getting no response. Patients who needed consultations were never getting them and were just assuming it was because of the usual waiting lists. And then sometimes the doctors would write a second letter, and that would be ignored too.

An interesting addendum to this ignoring mail business is that when the Health Information and Quality Authority (Hiqa) started writing to Tallaght Hospital repeating its requests for an inquiry into the X-ray backlog last year, these letters were ignored too, presumably lying unopened somewhere.

And now, what seems to be emerging is that GPs from around the country are starting to come out of the woodwork and saying, "My urgent referral letters are often ignored too." It is now emerging that this is possibly common practice throughout the country, that in the health services you just stick your head in the sand, go into catatonic, unresponsive mode and start ignoring urgent letters about suspected serious health conditions.

Tallaght hospital's answer to ignoring these urgent letters is that there were never 30,000 of them lying unopened, as had been claimed initially. There were, it says, at one stage 3,500 of them, and this backlog has now been dealt with.

However, as Professor Tom O'Dowd points out, the numbers from Tallaght Hospital have not been reliable up to now. Also, given that Tony Holohan, the chief medical officer at the Department of Health, admitted that many of these letters go back to 2002, you have to wonder why there were only 3,500. Of the tens of thousands of urgent referral letters written by concerned GPs, was Tallaght Hospital picking and choosing which ones it would ignore? Was it a lottery as to whether your suspected skin cancer or other serious illness came to the attention of anyone in the hospital? If the letters go back a number of years but there are only 3,500, then we can only infer that letters were selectively ignored, that not all letters were ignored.

And O'Dowd is right to doubt Tallaght's numbers. Let's not forget that the culture in Tallaght and the Health Service in general seems to be to dissemble and cover up until you are caught red-handed. The number of X-rays not looked at went from an alleged backlog of 4,000 which would be cleared by last July, to nearly 60,000, as more questions were asked.

The lack of basic communication suggested by the letters scandal is echoed in Hiqa's efforts to find out what was going on about the X-rays all last year. When it meets former CEO of Tallaght, Michael Lyons, in late June, it is given the 4,000 figure and told it would be fixed by July. When Hiqa meets him again in August, it gets more assurances. Hiqa is concerned enough to seek a written report on the matter in September. It repeats its concern and its request for an inquiry in letters in October and November, and the letters are simply ignored.

Professor Kevin Conlon, the current CEO of Tallaght, says that he found out about the problem only on December 14, despite the fact that in his previous job he was apparently present at meetings about the matter prior to then. While understaffing and a lack of resources are clearly a problem here, there is evidently a basic breakdown in information being shared in the health service, a lack of the kind of communication that the rest of us take for granted. Would a major issue like this be allowed to fester, ignored, where you work? Would everyone be able to ignore a growing pile of thousands of urgent letters that concerned people's health? It is unthinkable in the real world.

Some of the problems in Tallaght are clearly symptoms of a top-down malaise in the health service. I asked Dr Maurice Gueret during the week if he thought Harney should go. Gueret is a GP, editor of the Irish Medical Directory, and sat on the old health boards. He is passionate and compassionate about patients, but brings a healthy scepticism to the politics of health. Not only could Harney go, he reckons, "but her entire department could disappear tomorrow and nobody would notice -- except perhaps Qantas airlines. Once it created the Frankenstein that is the HSE, the Department of Health no longer had a purpose. Five hundred-odd non-regulating regulators sitting in an eyesore, writing speeches and press releases, shuffling Dail questions back and forth to the HSE".

So the inefficiency and the cancer begin there. The HSE is brought in, but no-one can be got rid of

from the now redundant Department of Health, so they all keep their jobs anyway.

Gueret said that political meddling in hospitals was at the root of the mess in Tallaght. "Tallaght is a particular case. It has been labelled a flagship hospital but has never been funded or managed like one. The relationship between Tallaght and some politicians has been poisonous. There is a feeling at the hospital that it has never been supported at a high political level and that lesser politicians just use it to score points off each other. It's certainly not an attractive place for a new consultant to go. It is not now a designated cancer centre. It is losing the children's hospital. It is grossly understaffed in some areas -- for 10 years it had just one casualty consultant to provide 24-hour cover. To meet international standards, it should have had 12 of them. It treats a catchment population bigger than Cork city and county, yet Tallaght has less than seven radiologists versus 27 in Cork."

The health service is rotten down to the tips of its toes. It needs massive and immediate reform. Such a system would not have been allowed to continue anywhere else, where you simply ignore a growing crisis, deny deny deny when you are caught out and then cover up and cover your ass when it blows up. The fact that the people of this country who pay enormous taxes and health insurance can't even rely on a health service that works, shows that the public sector needs to be urgently reformed.

This kind of reform would be a matter of fact in any other organisation. But in the public sector it is something it might consider doing if we are nice to it. Practically every organisation I know has been rationalised and reformed in the last few years, and this rationalisation has been accompanied by both job losses and pay cuts. We simply can't afford the old way of doing things any more. The public sector wishes to be paid more in order to make its sector fit to do its job. According to Jack O'Connor and Peter McLooney, it is the public sector's inalienable right to operate badly and if we want it to operate properly then we need to coax it. It's madness.

In the meantime, it seems that the strikes that are not strikes will continue. And who will they hit? As they used to say about cuts, they will hit the old, the sick and the poor. They will continue to affect those who are trying to collect their dole, their pensions. For 48 hours next week they will affect those who need to go to any of seven hospitals in Dublin, because the staff there are not getting the 6 per cent pay rises they are due under Towards 2016. This action will also affect working parents as they need to take days off to coincide with school closures. Peter McLooney has threatened the country with "Armageddon". This Armageddon will affect the most vulnerable in our society because these are the people who are most dependent on the public sector.

It is difficult to know if there is an appetite for this Armageddon among public sector workers themselves. Siptu has already expressed its unhappiness with proposals by Impact and the Irish Nurses and Midwives Union for rolling two-hour stoppages. Siptu expressed a desire for more intensive action. Perhaps the wonderful men and women who see people through what can be one of the most vulnerable and scary parts of their lives -- the birth of a baby, in various circumstances -- know too much about the effects of their actions to want to take more intensive action.

And that's worth remembering. There are wonderful people working in the public services, who do amazing jobs above and beyond the call of duty, dealing with the most vulnerable people in our society in health, education and social welfare. And they are ill-served by the unreformed systems in which they work, and they are ill-served by their union bosses alienating the rest of us by threatening Armageddon on a country that already feels like it has been trampled half to death by the four horsemen of the Apocalypse.

The phoney war between public and private sector might suit Peter McLooney and Jack O'Connor, by getting them back on the telly and by making them look relevant. But until McLooney and O'Connor understand Ireland right now -- a country where everyone, public and private sector, really only wants to pull together to fight the common enemy of potential obliteration -- then they remain irrelevant.

Sunday Independent

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