‘Patients’ Assembly’ would help us break ‘Groundhog Day’ in an unhealthy system
HEALTHCARE professionals have long been warning about the inevitability of what has – again – swamped our A&E services and the wider acute system. So have healthcare analysts.
Exactly a year ago, I pointed out in these pages that “what’s happening in A&E departments around the country is not a crisis. It’s the way things are done in Ireland. The increased prevalence of flu in winter is not a surprise, we really should have seen it coming last budget time – many medics did.”
The quality of care is excellent once you get inside the acute hospital system. The problem for many is access.
It’s been this way for a long time, something that should not be acceptable: “For some time, it has been evident that the capacity of our acute hospital system has not kept pace with the increasing demands being imposed on it. The consequences of that under capacity are well known, ie cancellation of elective admissions, long delays in accident and emergency departments, waiting lists for elective procedures and unacceptably high bed occupancy levels in the major hospitals.”
That was former health minister Micheál Martin, introducing ‘Acute Hospital bed capacity: a National review’ back in 2002.
This year, the Government’s response has been much the same as last year. Expressions of frustrations, apologies to patients, and praise lavished on staff working under serious pressures. And, predictably, promises of more ad-hoc funding.
When systems seize up, worldclass organisations seek to understand the facts and the root causes. But we know the facts. We knew them back in 2002 and indeed long before.
We know there is not enough capacity in the public system to deal with existing pressures, let alone those arising from changing demographics. We know bed occupancy rates are far too high and staffing rates too low. We know excessive pressures in A&Es affect the whole acute system.
Everyone wants an adequately funded public hospital system, but we don’t have one. Until we do, we need all the help the independent sector can provide – and provide at an extremely cost-effective rate.
Crucially, we know we don’t have nearly enough consultants and that there is a perennial shortage of nursing staff.
And we know these facts are not being taken adequately on board in the planning, funding and delivery of acute healthcare.
A system that is in semipermanent dispute with consultants about contractual arrangements cannot deliver consultant-led care.
Equally, if a significant proportion of our nursing graduates, having completed a demanding four-year degree programme, consistently want to emigrate – leaving the system dependent on overseas recruitment – then you have to ask serious questions about the terms and conditions of employment.
If you consistently underinvest in capacity – the data is unequivocal on this – then there are going to be bottlenecks, shortages and inefficiencies in the system.
There have been initiatives of one kind or another, as well as new structures, but not nearly enough or in a properly ‘joined-up’ manner.
Much more could be done in terms of engaging with GPs and allowing them to play a fuller and more substantive role within the acute system – including, where appropriate, A&E departments.
Pervading this reactive mindset are old mythologies about the process of funding of healthcare which are making a bad situation worse. Healthcare is, and has long been, systematically underfunded.
This inevitably produces an ‘overspend’ – a ‘mythical’ overspend. This underfund/ overspend cycle would appear to be mainly about control. It shifts responsibility – and blame – from the political process over to the hospitals and, implicitly, to hospital management and healthcare staff.
The consequences of mythical ‘overspends’ are more reporting, more oversight, and yet more control. It’s a nonsense.
It creates stress and a mind-set of dependency. Importantly, it makes a partnership approach to budgeting more difficult. It also allows the Government to get kudos for
If a significant proportion of nurses wants to emigrate, you have to ask serious questions about their terms and conditions
providing ‘supplementary funding’.
Expenditure on healthcare is an investment – one that generates real economic value – just like investment on roads and railways and IT. The official mindset still seems to be that expenditure on health is a bottomless pit. It doesn’t have to be and doesn’t justify the current way of thinking.
Paradoxically, the underspend existed side-by-side with the use of private health insurance as a cash cow to subsidise inadequate public spending – subverting attempts by families to deal with the consequences that Government underfunding has helped create.
The culture of an organisation is hugely important. Control and dependency drains performance. By contrast, a culture of positivity and trust brings with it enormous leverage in getting things done.
What is at issue is a clash of cultures. The State thinks in terms of control and of contractualism. Medical and nursing professionals think primarily in terms of vocationalism.
Problems arise when the State reserves the right to itself act contractually – but expects healthcare professionals to respond vocationally. The key test is this: does working in the HSE make the heart beat faster – because that’s the mark of a world-class culture – or is it just ‘a good job’ for people, many of who would like it to be a whole lot more.
Why is this not being addressed? The political process increasingly appears to be intimidated by the challenges of aligning new technology-intensive healthcare models with the legacy systems and processes that litter acute care.
The impact of the austerity cuts scarred and spooked politics – as well it might. The priority now seems to be ‘just keep the show on the road’.
BREAKING out of the ‘Groundhog Day’ syndrome will require a change in corporate culture as much as in the budgeting system and the economic benefits of investing in healthcare.
What’s also required is a ‘democratisation’ of policy-making in acute healthcare. The public are on the outside looking in. They shouldn’t be. It would be much more sensible if they were fully informed about what it is that doesn’t work and to have their voice heard on how it could be improved.
A Citizens’ Assembly-type forum – not the assembly itself – would systematically open up the workings of the whole acute system to the public. Soundbites, spin and social media do not do the job. Nor do Dáil questions or speeches.
A ‘Patients’ Assembly’ if you will, independently chaired and not hostage to political or professional agendas, would give the public access to experts in a structured and open-ended manner. It would draw the public into an understanding of why the system is not working and how it might be made to work.
With the right mandate and a short and snappy timeline, it would help cut through the old mindsets and mythologies and help the country to finally break out of ‘Groundhog Day’ in A&E.