NOW IS THE TIME TO FIX OUR BROKEN HEALTH SYSTEM
Long waiting lists, patients on trolleys, a host of testing scandals – our health service is failing us. We badly need more candour, which is why...
THE last few weeks have been particularly depressing for those of us who care about our health service. More importantly they have been very worrying for those who depend upon it.
Most commentary and attention has understandably been focused on the suggestion that there has been a systematic, catastrophic, life-threatening failure at the heart of our national cervical cancer screening service. It is possible that there is, but it is also possible that there is not.
There is, on the other hand, exactly no doubt that other critical, health-compromising and life-threatening problems remain unaddressed. The failure to deal with these problems goes, I believe, to the heart of the dysfunction in our health service.
Despite having a second-tonone cohort of nurses, doctors and other professionals, our health service is unfair, inefficient and all too often mediocre in quality.
I refer in the first instance to our appalling, internationally unprecedented waiting lists for all types of routine tests and treatments, and secondly to the rapidly developing professional staffing crisis which is increasingly blighting the system. Another worrying trend is that we have become a ‘lowaccess-to-new-drugs’ society.
The intractable waiting list problem is particularly dispiriting.
I wrote in this newspaper in 2009 about the waiting time for corrective surgery for children with curvature of the spine, a condition known as scoliosis. This was in the context of a broader article about the underfunding of Our Lady’s Hospital for Sick Children, Crumlin. Despite my highlighting of this issue, no definitive action has been taken over the scoliosis waiting time problem in the intervening years. Five ministers of health and a boom/ bust/boom cycle later, the problem is still unresolved, and still attracting headlines and political hand-wringing.
HOW can anyone be anything other than amazed that the waiting lists for cataract surgery in a modern Western country are up to five years in places? Anyone who has ever spent a day coping with lost spectacles knows how disabling this minor inconvenience can be. Imagine waiting five years for sight-restoring surgery when you know your blindness can be fixed in what is usually a 30-minute operation.
We were told that the problem causing waiting lists was the distraction of consultants from their public duties by private practice. New contracts were introduced for freshly minted consultants which limited their private practice rights. Did waiting lists get smaller? No, they are still ballooning.
The waiting list problem is principally due to the system we use to fund hospital care. Hospitals are given fixed amounts of money by budgetary fiat, and often in response to an inter-institutional beauty contest adjudicated by the HSE. They are then told to make it last to the end of the year. Good hospitals get no more. If more patients wish to avail themselves of the services of a better-performing institution, no additional money goes to that institution, and the waiting lists go up.
As one of the principal metrics that health bureaucrats and hospital administrators are judged by is ability to come in on budget, there is a powerful incentive for both inefficiency and inactivity. How so?
If money is running tight by September, well, close a ward for painting, or maybe an operating theatre or intensive care bed due to staff leave. It can thus be seen that waiting lists are not a failure of the HSE business model. They are in the model. They are the model. Keep costs down by making people wait.
Remember, in the current system, a patient who is on the waiting list is free. They only cost money when they enter the hospital.
This, of course, is a totally false economy. The waiting times for surgical treatment of severe life-threatening obesity have been up to seven years. Those patients’ annual health costs plummet when they have the operation. However, the annual surgical budget would be exceeded, so ‘make ’em wait’ has been the HSE motto. As they say in Brooklyn, ‘go figure’.
If, on the other hand, reimbursement was linked to activity, efficiency and high quality, then waiting lists would disappear overnight.
Such systems are possible within a socialised framework, such as the German system. This type of activity needs to be policed to prevent doctors and hospitals gouging the exchequer by doing unnecessary treatments, but other
countries do it and succeed.
Medical staffing in Ireland is also nothing short of bizarre. Here are some of the astonishing paradoxes about Irish health care.
We have the highest number of medical schools per head of population of any Western country, producing more doctors per head of population, while simultaneously having the lowest number of doctors in career-level posts!
Incredibly, we are one of the leading exporters of doctors, while simultaneously being one of the leading importers of doctors. To complete the paradoxical circle, the countries we import from are desperately short of doctors.
The phrase ‘you couldn’t make it up’ has resonated in my head for years.
As a result, we have a very distorted career pyramid, with far too much of our health care delivered by trainee doctors.
The absurdly low number of specialists is also driven by economics. Is it because we are paid so well? While Irish medical salaries are high, they are a very small part of health costs.
The principal economic benefit of curtailing doctor numbers is curtailing their activity. Doctors do operations, give treatments, order expensive tests, etc. The fewer we are, the more people wait to see us, the bigger the saving.
To paraphrase the Clinton campaign: ‘It’s the business plan, stupid.’
I am a believer in socialised medicine. I believe that healthcare should be administered in accordance with need, not according to ability to pay.
I believe that better-off people, like me, should pay more so that we ensure that everyone gets the health care they need. I just don’t believe that the HSE command and control globally budgeted inflexible bureaucratic model is the right way to deliver it.
I am in good company on this. Fine Gael went to the country in 2007 and 2011 promising root-andbranch reform of the health service and the introduction of universal social insurance. Minister James Reilly stood down the HSE board as part of a planned phased closure of the whole health service.
LAST week, Health Minister Simon Harris announced that he will reappoint it. There is no will to reform the health service in this Government.
So what of the screening scandals? A prevailing narrative is that a penny-pinching bureaucracy, inspired by successive neo-liberal governments, cost hundreds of women their health, and in some cases their lives, by awarding a contract for crucial medical laboratory services to a dodgy, cutprice, fly-by-night American company, an organisation whose shoddy work led to crucial delays in diagnosing cervical cancer, and to needless deaths.
This version may be entirely true, but it may also be incorrect.
How, you might argue, could it be anything other than true when we have seen the terrible personal tragedies which have been visited on many women and their families by screening failure? These tragedies have absolutely happened.
The answer is that screening by cervical smears is not a precise technology.
For instance, a cervical smear would not be the test of choice for a woman who presents to her doctor with complaints such as bleeding or pain, symptoms which might indicate cervical cancer or which might have an altogether more innocent explanation. Other more precise tests would be used.
No, population cervical screening is a strategy which is designed to reduce the number of women in the screened population who will develop, and possibly die from, this terrible disease. Until the recent advent of HPV vaccination, it was our only real defence.
It is disturbing, indeed, to see how many of the politicians who were most vocal about the screening tragedies had previously sided with the opponents of vaccination.
Widespread screening has substantially reduced the burden of cervical cancer in most Western countries. While still the fourth leading cause of cancer death in women worldwide, in the West it is now outside the top ten.
Screening has not and cannot reduce the cancer rate to zero. In a recent large study in the British Medical Journal, it was reported that for every 100,000 women who have a negative smear test (ie, normal), approximately 50 will still develop cancer.
When, after the patient has developed cancer, the previous smear is re-checked, about half the time the checker will disagree with the original normal result. It is always easier to go back and spot an abnormality when it is known for sure that there was indeed an abnormality.
SCREENING healthy women with breast X-rays (mammography) is a case in point. Screening populations of healthy women with mammographic X-rays will result in an approximately 20% reduction in mortality in the screened population. One thousand screens will pick up eight cancers and miss one. Our BreastCheck service has recently received the highest level of accreditation in an international audit. However, there is no such thing as an ‘all clear’ with screening.
If there is a departure from international quality standards in CervicalCheck, we need to know.
It should be easy enough to determine if there is, in which case we truly have a scandal on our hands. We also need to know if there isn’t.
We need the inquiry, led by Dr Gabriel Scally, to address two readily answerable questions. In the first place, is there a higherthan-expected rate of false negatives in our cervical screening program? Secondly, is there a disparity in outcomes between the various laboratories which are providing the service?
I personally have an open mind about the possible answers to these questions, but I must say that if I had to place a bet, I would guess that CervicalCheck is probably performing at or about the same level as most high-quality international screening services.
While I believe that doctors have an obligation to be honest with their patients, the duty of candour with respect to screening has been evolving.
The relationship between a patient who seeks out a doctor has been felt to be different to his/her relationship with a government, which calls you in unbidden for an imprecise screening test.
The UK, which has one of the best organised cancer screening services in the world, only specified this duty of candour in screening in 2016.
This is a new idea. And it is, I believe, a good idea.