Thursday 18 July 2019

Political interests infect every move to reform health system

Health Minister Simon Harris with Dr John Murphy at the National Maternity Hospital, Holles Street, Dublin Photo: Colin O'Riordan
Health Minister Simon Harris with Dr John Murphy at the National Maternity Hospital, Holles Street, Dublin Photo: Colin O'Riordan
Eddie Molloy

Eddie Molloy

About 18 years ago, when I was invited to engage with the Department of Health, I requested copies of relevant documents that I should read in advance of meeting with officials. A few days later, two men in a van arrived at my door with two large plastic crates containing over a hundred reports, plans and reviews. Since then, successive health ministers have added a few hundred more to the pile and this week yet another review of A&E overcrowding is promised.

A year ago, Tony O'Brien, CEO of the HSE, told a Dáil committee that there is no shared political vision of the health service, and a week later Taoiseach Enda Kenny commented: "...and that's why everything is haphazard". In this context, the most important initiative taken by Health Minister Simon Harris has been to establish the all-party Future Health Committee, chaired by Róisín Shorthall TD. Its task is to seek political consensus on a 10-year vision for the health service, a clear picture of what it will look like in 2020.

In the midst of the latest A&E crisis, there is general agreement that nothing short of a fundamental reorganisation is required if our health service is to provide access on the basis of need (and not ability to pay), safe care, high quality outcomes and value for the €14bn being spent on health.

That is why so much is riding on the work of the Shorthall Committee, whose biggest challenge will be political, not technical. The ultimate cause of the enduring shortcomings of our health service is the blatant politicisation of decisions about everything from the location of hospitals to the provision of a scanner.

In his book 'The Innovator's Prescription', Clayton Christensen provides the outline of what a transformed health service might look like. He notes that there are three broad types of medical condition or disability and he argues that each requires a different (though linked) 'delivery system'.

The first is acute, complex cases - the clearest example being a victim of a serious car crash -which require multi-disciplinary teams running a series of tests to figure out what is wrong and what might be the best treatment. The proper setting for these patients is a general hospital, manned by highly experienced staff, who in the toughest cases rely on what Mr Christensen call "intuitive medicine", as they try to solve each unique problem presented.

The second type of condition is one where advances in medicine have arrived at a clear, agreed understanding of the nature and causes of the ailment and of the best solution. Examples would include the removal of a cataract, or a hip replacement. The best setting for treating these patients, in terms of quality of outcomes and cost, is one that specialises in carrying out these procedures.

An example of how these 'solution centres' work is the cardiovascular service in the Galway Clinic. A comparison between the services in the clinic and Galway University Hospitals showed that costs in the former are 30pc lower per procedure (eg dealing with varicose veins) and that there are better outcomes (eg, fewer amputations). The reasons for this difference include fewer role demarcations in Galway Clinic, four to five, versus around 10 in the hospital; treatment in office-type settings versus more expensive surgical facilities; and sheer repetition, which drives the continuous process improvement that delivers safer, better, less-costly outcomes.

The third type of condition is chronic illness and the best care setting for this ever-growing category is a network of services based in the community and anchored to each individual's GP. These actually exist in a few pockets around the country.

Having set out his stall, Mr Christensen then makes the obvious point that trying to provide all three kinds of service, safely and efficiently, in the one general hospital setting is suboptimal. Right now, A&E is overwhelmed by patients whom everyone agrees should be treated in the community.

Furthermore, a large proportion of the 'elective' surgery cases that are routinely cancelled in general hospitals in order to cope with A&E overload involve the kind or relatively standard diagnosis and treatment that 'solution centres' provide. They constitute the bulk of conditions which have 535,000 people - one in 10 of the population - waiting more than a year to see a consultant.

The radical reorganisation of our health service now being called for will entail changes in every aspect of how, where and by whom services are delivered. It will involve massive reallocation of money and staff from hospitals to GP services and community supports. For this reason, while we need more doctors and nurses right now to cope with the demand, all new contracts should anticipate possible redeployment down the line, as the new design of the service unfolds. You don't pump additional resources into dysfunctional systems.

Such a historic, national programme of transformation would require a skilled, well resourced 'programme office' and a large, ring-fenced budget. Tony O'Brien, asked on radio to put a figure on it, replied: "Hundreds of millions."

My own gut feel is more like a billion euro and 10 years to do it. One of the reasons we have such chronic, seemingly intractable problems in the health service is that the HSE has never, since the outset, been given the necessary resources to plan and implement change. This explains the van-load of reports, many of which merely repeat the prescription of earlier, unimplemented reports.

Adopting this longer-term, strategic perspective does not mean that nothing can be done to alleviate the A&E problem in the meantime. Quite the contrary.

A feature of our health service is the variation in practice and performance across the country on everything from hygiene scores to absenteeism. Listening to doctors, nurses and union leaders who spoke out over the past 10 days, it is clear how such variation is magnifying the A&E crisis.

For example, 'escalation', which entails moving trolleys from the overcrowded emergency area up into the wards, is still being resisted in some hospitals, although a national agreement to adopt this tactic was negotiated a year ago. Why? Direct referrals from GPs to consultants, by-passing A&E triage, happens in some hospitals and not others. Why? Senior decision-makers are more available in some hospitals outside nine-to-five and weekends to discharge patients. Why?

Astonishingly, only 55pc of frontline medical staff opted to get the flu vaccine, and their spokespeople insist that it should not be made compulsory. This is surely unacceptable on health and safety grounds, if only to protect patients, whatever about the madness of health professionals not protecting themselves.

During the week, we learned that a large percentage of people in nursing homes, all of whom are probably taking some form of medication, didn't get the flu injection and ended up spreading it to fellow residents and adding to A&E woes.

In summary, a great deal can be done with existing resources to mitigate the scale of recurring A&E crises, and the responsibility for taking these steps lies largely with local management.

Mr Harris is right to demand managerial accountability - that is, accountability with consequences. As things stand, however, there is no effective system for holding managers accountable within the HSE. The Shorthall Committee would do well to include this decisive element in its 2026 vision.

Also, let's hope that their findings will secure wide political support and - still dreaming - trigger planned implementation of the long-awaited programme to transform of our health services.

The last thing we need is another report that is killed off by political and professional vested interests and ends up in a crate somewhere in the basement of Hawkins House.

Eddie Molloy, management consultant, specialising in large-scale organisational change and innovation

Irish Independent

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