Wednesday 18 September 2019

Eilis O'Hanlon: Treating doctors like gods makes mistakes more likely to happen

It's not healthy to grant power without challenge to a small group of people - especially when political oversight is so poor, writes Eilis O'Hanlon

Tony O’Brien, the Director General of the HSE
Tony O’Brien, the Director General of the HSE

If any confirmation was needed that those in charge of the Irish health system still haven't understood why the cervical cancer screening scandal has caused such anguish, the statement issued by the Health Service Executive (HSE) last week should remove all remaining doubt.

The statement correctly went out of its way to reassure patients that the cancer screening regime was "safe and effective and that the quality of the laboratory testing carried out by the programme is as it should be". The last thing anyone wants is to discourage women from availing of a service which saves lives. It's terrifying to think of the number of mistakes that are routinely made, and how fatal the consequences can be for the small number of people affected, but all screening programmes have a margin of error. The important consideration is what happens when mistakes are identified.

That's where the distress originates, and that's what the HSE is apparently still struggling to comprehend, since it ends its statement of reassurance to women by stating: "We are committed to sharing information and to letting people know what's happening now and what will happen next."

If that was truly the case, some of the fear and trauma which has been aroused by this scandal could have been allayed from the start. What the HSE should be answering is why the scores of women affected by errors in the cervical cancer screening programme were not given the benefit of that sharing of information to which the HSE insists it is committed. Why were they not told what was happening to them and would happen next?

The answer to that goes right to the heart of how doctors are both seen and see themselves. They're accorded too much unquestioned authority, and that's never healthy when it comes to fostering accountability, humility, probity. They see people at their weakest and most vulnerable, and those patients naturally place their entire trust in the treatment they're receiving. As they should. On the whole, Irish patients get world-class treatment.

But it's still not healthy to grant so much power without challenge to a small group of people, investing them with near god-like levels of omniscience. Being constantly deferred to in this way makes mistakes more likely to happen, and less likely to be identified or remedied quickly when they do.

Simon Harris, TD, Minister for Health. Photo: Damien Eagers / INM
Simon Harris, TD, Minister for Health. Photo: Damien Eagers / INM

Studies regularly show patients are wary of questioning their treatment, because they fear getting a reputation for being awkward. They don't feel their input is encouraged or welcomed by doctors. That's why it's so important for the organisations which have grown up around medicine to provide a counterbalance to medical arrogance. Instead, the bureaucracy has itself been infected with the same pride, imagining they too should be accorded similarly unchallengeable authority.

There was a debate going on internally in the health service as to how to respond to the audit of the slides which found that so many Irish women had been given false negatives in their screening results, but they still clearly felt it was up to them to decide what should be done with that information. It was a debate the medical establishment was having with itself, not with patients, and there was not, within the HSE, a sufficiently robust culture representing the rights of patients to information. They treated information as if it belonged to them, and it was their decision what to do with it.

That state of affairs is only allowed to continue because so many people outside of the Irish health system go along with this sense of entitlement. That includes politicians. Ministers now say they're as outraged as everybody else by what has happened, but do they have that right to righteous anger?

They would have if they were as much in the dark as patients, and had no way of switching on the light, but the current attempt to distance themselves from what Sinn Fein has rightly called a "toxic culture of unaccountability" is an unconvincing act at best.

Firstly because both of the main parties have gone along with the practice of allowing voluntary, rather than mandatory, disclosure of vital information to patients, making it inevitable that abuses of trust will occur. Secondly, because it can hardly have come as a surprise, considering recent history.

Five babies died at Portlaoise's Midland Regional Hospital between 2006 and 2012. A review into the quality and standards of maternity services at the hospital, commissioned by former Health Minister James Reilly, was undertaken by a six-person team from the Health Information and Quality Authority (Hiqa). A draft report made 250 adverse findings against the hospital, as well as stating that senior corporate management at the HSE was partly at fault for some of these failings. The HSE's response was to claim, in the words of director Tony O'Brien, that the report was "unfair", "lacks context and balance", and had been "prepared in breach of fair procedures". He also said the report would "shatter confidence" in the HSE.

At one point, the HSE even considered suing Hiqa over the report. Following intervention from the Department of Health, both sides agreed to a bilateral process to resolve their differences.

Who was the Minister of Health at the time? Leo Varadkar.

This sort of nonsense has been going on for decades, and there is no will to challenge it. In the case of the baby deaths at Portlaoise, the government's main priority was smoothing over the difficulties between the two agencies. That's typical of how government operates. It neither anticipates problems before they arise, nor robustly tackles them when they do. Instead it treats crises on a case-by-case basis, seeking to calm the storm, then moving hurriedly on, until the next time. There's always a next time. Crises are inevitable.

The emphasis should be on what measures are in place to deal with them when they do. Health Minister Simon Harris now lauds Vicky Phelan, who defied an attempted confidentiality clause after she was left with inoperable cancer as a result of a botched slide reading; but if she'd stayed silent, what would he have done to ensure these tragedies didn't happen again? How can anyone be sure things would have changed?

There is now to be a statutory investigation into the cervical cancer screening programme. That's as it should be. But there are plenty of things which could be done immediately without the need for an inquiry, or that should have been done already. Ministers could be doing much more to foster a culture of transparency. To insist that patients have a right to information in their medical records.

To uphold the Ombudsman's statement of good practice for the public health service in dealing with patients which states that "information should be withheld from patients only exceptionally, when there is good reason to believe that this information would, without any expectation of obvious positive effects, cause them serious harm".

The reason 162 of the now 209 women whose false test results were discovered following an audit were not told is because there was no insistence that they must be told. In plenty of other cases, patients have been forced to go through solicitors to get access to their own medical records, information that should be theirs by right. It's justified that the spotlight should be trained on HSE director Tony O'Brien, whose resignation Vicky Phelan has called for, and that political support for his position is running out, with Fianna Fail and Sinn Fein both now calling for his removal.

He is, as Employment Affairs and Social Protection Minister Regina Doherty said last week, "in charge of making sure that the services he delivers... are safe, are timely, are reflective of the needs we have and can be trusted". But isn't that also a perfect summation of the government's responsibility ?

Simon Harris says he ordered "immediate change" when he became aware of what was going on, but what had he done before that to challenge arrogant, closed thinking inside the Irish health service, from the HSE down, and ensure that patients were protected from that institutional power?

What questions did he ask? Or did he just cross his fingers and hope the HSE and doctors were all doing the decent thing?

There is no excuse for not recognising the vulnerability of patients faced with the combined might of the political and medical establishment, and anticipating the need to have their backs; but the Taoiseach himself made the same meaningless noises when he spoke about this scandal last Friday, saying: "At the heart of it once again, unfortunately, was a failure of open disclosure by doctors and also a failure by senior management to make sure that that happened."

He also insisted there was the need for a "culture change" within the health service. If only he was in a position to do something about it.

Vicky Phelan has expressed her own frustration with politicians, telling The Ray D'Arcy Show: "No one speaks their mind and comes out and tells it as it is."

That's it in a nutshell. They all have an investment in the system. They all stay schtum, seeing themselves as managers rather than pro-active reformers or advocates for patients. The reason this scandal came about was because of a culture which does not value or promote transparency, and that rot comes from the political, as well as the medical, establishment.

Ministers who seek credit for successes in hospitals should not be allowed to pretend that failures have nothing to do with them.

There will always be mistakes in medical treatment, and there's no evidence that those errors are any more prevalent in Ireland than other comparable countries. Germany, France and the UK have been rocked by equally horrible scandals. Pretending Ireland is uniquely awful is self-indulgence.

Nor is it helpful to present what happened as proof that Irish women are treated in a disproportionately uncaring manner. There is no evidence for that. Women are tested for cancer much more widely than men, and hospitals are fortunate to have so many female doctors and managers at all levels.

Male patients are equally let down by a system which denies them the right to full disclosure.

Rather, this is about a culture of imperial corporate unaccountability, compounded by excessive deference to medical authority and weak political oversight, and it's been around far too long for ministers to suddenly express shock or surprise at its existence.

Sunday Independent

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