Five critical ways to reform our ailing healthcare system from the inside out

Medical professionals need to lead, and they need administrative and political support in order to do so, writes Stephen Donnelly

IN THE United States, healthcare is referred to as the ‘third rail’ of politics. The saying comes from the subway system, where the third rail is the one with the electricity going through it. Hence the analogy — if you touch it, you’re dead. A phrase with which Minister for Health James Reilly can probably empathise. No matter what healthcare ministers do, no matter how smart or hardworking they may be, messing with people’s medical care, or the powerful vested interests in the medical industry, tends to go badly wrong.

In a growing economy, you might get away with it. You can merge your regional health authorities without reducing staff numbers. You can allow branded drugs to be used when cheaper generics are available. You can ignore hospitals that refuse to implement life-saving recommendations from expert reports. By wasting enough taxpayers’ money, you can avoid modernising your healthcare system without too much political fallout.

That was us six years ago. Then the economy tanked, the deficit exploded, and urgent, profound and widespread reform of the entire system was needed if we were to continue providing decent care with less money. But six years on, substantial reform has yet to materialise. And so here we are — the healthcare budget is creaking, patients are scared, healthcare professionals are demoralised and politicians are calling for the health minister to quit. Again.

We need a new approach. Before being elected to the Dail, I had the privilege of working in healthcare reform abroad. Here are five characteristics of modern healthcare I’ve seen elsewhere, that I believe could work here:

1. Find clinicians willing to lead, in public as well as in private. Doctors tend to listen to other doctors. So if you want big improvements, they’ve got to be led by clinicians. This is happening, in private, in parts of the system. For example, treatment is being aligned to clinical pathways (eg, for stroke, heart attack, cancer, diabetes, etc). But our clinicians, for whatever reason, are reluctant to take a more public leadership role.

This matters a great deal. Some of the changes required to modernise our system, taken in isolation, meet serious public resistance. As such, they don’t get the necessary political support. For example, changing the mix of work a local hospital does might be eminently sensible in the context of reconfiguring the system. But local communities tend to hear only about what is being stopped. And, naturally, they resist. Politicians are typically left to try and explain the bigger picture, but why would anyone believe them? They often don’t have the bigger picture anyway, but the doctors do. And they will be believed by the public. Who’s going to object to local changes if the medical community explains how lives will be saved? If we’re going to drag our healthcare system into the 21st Century, our medical community has a key public role to play.

2. Come up with a national plan, and explain it. When I was elected, I went in search of the healthcare strategy for my constituency — what services the population needs, and how the healthcare system is evolving to meet those needs. Turns out no such strategy exists. The closest document I could find is the ‘Regional Service Plan’, which is little more than a list of existing healthcare assets. Just think how much opportunity there is in matching provision with need.

Also, in reconfiguring our healthcare system, even if the wider impact is positive, there will be winners and losers locally. With a national plan, people can understand that while they may be losing something locally, they are also benefiting from the impact of changes all over the country.

3. Give the power back to frontline workers. Some changes must be done centrally, like shifting from hospital-based to communitybased care. But within each unit, be it a hospital or a child-protection team, there is enormous untapped potential for improvement. In the case of the HSE, I believe a great deal of the problem stems from disempowerment of frontline workers, who feel they are fighting the bureaucracy when they should feel supported by it. The recent doctors’ strike over 24-hour shifts is a perfect example. Or the childprotection workers who recounted the conversations with their bosses, early in their careers, where it was explained that if they got into a tricky situation, they were on their own. Or the nurses who have shown me how patients could be treated more quickly and comprehensively, but whose ideas were never acted on by management.

The culture within the HSE needs to change, and that change can only be achieved if HSE staff, both clinical and non-clinical, are involved. The key is to understand this: the vast majority of HSE employees care deeply about our health service. They know how it can be improved at every level. They want to be challenged, to have the authority to make changes, to be recognised for great work, to be accountable. If they’re not doing their best, it’s usually because they have grown tired of trying to make a difference in a system that doesn’t seem to care. Of course, there are freeloaders — they exist in every large organisation — but they are a tiny minority who result in a disproportionate amount of negativity. A new, accountable culture tends to solve this problem pretty quickly.

‘Local communities tend to hear only about what is being stopped’

4. Provide the necessary training. In this new culture of empowerment, a little bit of training can go a long way when it comes to improving operational effectiveness. One example is something called lean process design. This is a method staff can use to analyse their own areas of work, identify bottlenecks and remove them.

Here’s an example. I recently brought my four-year-old son to hospital with a fairly deep head wound. In spite of him being covered in blood, it was over half an hour before he saw a triage nurse. There was only one doctor, and kids and parents were arriving faster than she could treat them. So the waiting room filled up, and the children got half-hour checkups from a fantastic team of nurses. Several hours later, this wonderful doctor glued my son’s wound back together, and we went home.

The solution? One more doctor and several fewer nurses. Lower cost, better service, but not happening. Once you know what to look for, you begin to spot these opportunities all over the place.

5. Measure healthcare outcomes so the system can keep improving. Imagine you had data showing you were twice as likely to have childbirth complications because your local maternity hospital wasn’t as good as the others. Or twice as likely to die in surgery because your surgeon wasn’t as good as his or her colleagues. Or twice as likely to contract MRSA because the doctors in your local hospital don’t wash their hands enough. Imagine the power of such data in finding good and bad practice, and in ensuring those bad practices were replaced with the good.

We have some of the finest healthcare professionals on earth. We spend a fortune training them. We entrust them with some of the most important and complex tasks in our society. The key to modernising our healthcare system lies with them. They need political and administrative support, and they need to lead. If we can realise this, and change our approach to reform to encompass it, we can go a great deal of the way to figuring out how to keep improving healthcare in Ireland, even in these tough economic times. Stephen Donnelly is Independent TD for Wicklow and East Carlow