How to finally fix what is wrong in our health service
It is essential to address why the obvious faults in our health service have not been corrected, writes Stephen Donnelly
In politics, giving voice to half-formed thoughts is generally inadvisable. But sometimes, our first impressions can provide insight, so let's give it a go.
Three weeks ago, I became Fianna Fail's health spokesperson. I've been reading reports, meeting clinicians, debating with Government and listening to patients. I'd like to share three initial reactions to what I've found.
The first is just how desperate the situation has become. There are more people on trolleys than ever before. There are more people waiting on hospital procedures than ever before. Seven in every 10 GP practices aren't taking new patients.
For children with a disability, early assessment is vital. In 2016, there were 3,200 waiting for an assessment. Today, it's 4,300. In 2015, there were 20,000 people waiting to see an occupational therapist. Today, it's 30,000. These figures go on and on - surgeries, mental health, home care, doctors on-call, respite, rehab, hospice, palliative care - in spite of more spending on health than ever.
Behind the figures are real people and daily struggle. Last Friday, I was canvassing in Wicklow. Over two hours, I met many people at their doors. More than half spoke of their experiences with the healthcare system. One lady, caring for her disabled son, couldn't get a respite day. When I asked when she last had one, she told me 'last June'. Another lady told me her daughter's been waiting for a wheelchair assessment for over a year. Parents told me of their children assessed as needing educational supports but unable to get them.
I'm working with a man left quadriplegic after an accident, discharged from the National Rehabilitation Hospital last September. He's still there because the HSE hasn't found anywhere for him to go. Since taking on the role of health spokesperson, my office has been inundated with stories like these and worse.
The second thing which has really jumped out at me gets far less attention. Many of our clinicians - doctors, nurses, physiotherapists, midwives, and other specialists - are exhausted, frustrated and demoralised. Some are at or past breaking point. Surgeons can't get access to operating theatres. Nurses are so burnt out they're leaving the profession. GPs are so frustrated they're emigrating.
We have a serious shortage of consultants in Ireland. But our future consultants, the non-consultant hospital doctors, are in some cases being treated with contempt. Some are forced to work 36-hour shifts. Others can't get days off or parental leave. Would you blame them for heading off to Canada or Australia? The most powerful healthcare asset we have, by a country mile, is our clinicians - and yet they are being treated like this.
The third thing I'd like to share is firmly in the territory of half-formed ideas, but here it is. We may be having the wrong conversation, or at least only half of the conversation we need to be having.
The political debate, media coverage, numerous reports - focuses largely on what's not working, what needs to change. Numbers of beds and doctors, integrated primary care, unequal access to care, digital records, mental health, early-years intervention, health promotion, neurorehabilitation, step-down facilities, palliative care, home care, clinical pathway design and so on.
It is true that changes are needed in all of these areas, but we know this, and have known for many years.
An interesting question, a more difficult question, but possibly a more useful one, is this: Given that we already know what needs to change, why has so little change actually occurred?
The answers to this question are undoubtedly complex, and I'm not convinced are well understood. They are certainly not well laid out or discussed, nor is there consensus around them. But we can lay out a few guiding principles guide the way.
One: Sustainable change in healthcare is only possible with the buy-in and leadership of clinicians. That means including them in figuring out what changes are required and how to make those changes happen. It means trust existing between clinicians, the HSE and government. It means ensuring clinicians are valued and energised by their jobs. These conditions are not currently met.
Two: High performing healthcare centres -including GP practices, primary care centres and hospitals - require local autonomy, funding certainty and aligned incentives. This includes multi-annual budgets, control over individual spending lines, revenue streams to match costs incurred, and much more. These conditions are not currently met.
Three: It is important to know what's happening at a pretty detailed level. Which hospitals are best at different types of clinical work? How many GPs are there? What procedures are being referred to hospital that could easily be done in GP surgeries for a fraction of the cost? This condition is not currently met.
We have some of the best trained clinicians on earth. Parts of our healthcare system are world class. We have a highly professional civil service and skilled HSE officials who want the same as everyone else - a great healthcare system.
We spend a fortune on healthcare, and in spite of all of this, desperation is being felt by patients, parents, carers, clinicians, and everyone in between. Why? It is not beyond our ability to make things better?
If we're going to succeed in that, we must ask, and answer, the right questions. Understanding what needs to change is not enough. We must get our heads around the related questions - why have things been allowed to get so bad? Why has so little change been achieved?
Stephen Donnelly is Fianna Fail TD for Wicklow & Carlow East and FF spokesman on health