We need a health system run by people who care – NOT the HSE

Surgeon’s excoriating view of a failed bureaucracy

THE accountants in the HSE like to break people down to numbers, so here’s one for them: 88% of final-year medical students have no intention of working in Ireland when they qualify.

That astonishing figure shows just how far we have let healthcare fall in this country. The reason is not just economics; being a doctor is a vocation but in Ireland it is intolerable.

No one goes through six years of medical school only to wind up more answerable to a middle-manager with a clipboard than to their patients. But healthcare in this country is ruled by accountancy, not care.

As a transplant surgeon, I’ve seen first-hand the lack of respect hospital managers have for patients. A few years ago in Beaumont, we had a problem with infection in the transplant unit. I approached one of the many, many higher-ups who told me: ‘You know as well as anyone else that your patients would be happy to have their operation on the side of the street.’

That is probably true, because patients are so grateful to their donors and everyone else that they’d accept anything for another chance at a full life. But it’s not the attitude the people tasked with overseeing the care of our sick should have.

In my area of transplantation we have three separate hospitals with transplant centres for no other reason than the vested interests of those institutions. That’s because a transplant unit means more funding into the hospital’s coffers – to be spent across every unit – so managers want to protect them. The result is services are triplicated and expertise is diluted.

IF WE had a national transplant centre, a dedicated environment, it would significantly ease the pressure on medical staff instead of stretching their time and resources across myriad different problems. This would be better for patients, and more cost effective.

‘Cost effective’ is the buzzword from the NHS that the HSE has now adopted.

Well, how cost-effective is it for the transplant unit in Beaumont to be in a portacabin? How cost effective is it that the pancreatic unit I set up in 1990 closed in January because I retired and there was no one qualified to replace me? How cost effective will it be when we have to start rationing kidney dialysis because we’re only doing half as many kidney transplants as we need to because there simply aren’t enough surgeons to make use of donated organs?

In Leeds University last year there was a job advert for a consultant transplant surgeon with the usual qualifications and experience. But at the end it said applicants would need to give a 10-minute PowerPoint presentation for the interview. The topic was ‘ How to save money for the trust’.

We’re just as bad in Ireland. It’s all about balancing books and cutbacks. There are not enough replacements when medical staff are ill or on maternity leave, yet there are ever-increasing levels of management. Two months before I retired, we learned that since 2011 the number of senior HSE executives had risen by 11%. In the same period, the HSE employed 744 fewer nurses. When money was available for a kidney transplantation unit in 2013, it should have meant more transplants and better care.

BUT instead it was spent on quality managers, risk managers, coordinators and the like. There was no increase in transplant nurses and, in fact, two transplant surgeons have left their posts in the past six months. The HSE trumpeted the notion that money would increase the number of kidney transplants from 150 to 260, but in January we had to export kidneys donated here because staff shortages meant there weren’t enough surgeons to do the operations.

We’ve had jobs in transplantation advertised for the past year with no suitable applicants. There were three positions in Beaumont and no applicants could be considered. We’ve had serious professorship jobs in Dublin and Galway where recognised experts have come back from the US to take the jobs. It wasn’t long before they realised they couldn’t hack the diversions of their energies into endless, pointless meetings.

Medical staff are trying to work in an environment filled with layer upon layer of managers with clipboards making it impossible to carry out their jobs efficiently. There are too many people involved between doctor, nurse and patient.

If 88% of final-year medical students are finding it intolerable here, the leaders of the medical profession need to ask themselves where they are going wrong. What have we allowed happen to medicine that it has become like this?

The reason the younger people are leaving is not economic: most leave because they really want to deliver care to patients.

This finance-based management style leads to a huge drive for more organ donation with little attempt to create an environment where surgeons can actually transplant them.

If we could do another 100 kidney transplants, which gives a patient an extra 15 years of quality life, we’d save the State €65m in direct medical costs by taking those people off dialysis. That’s not to mention the economic benefits of those patients getting back to work instead of being carted into a hospital for four hours of treatment three times a week. This is a nobrainer. But the impenetrable HSE system is hamstrung by its own bureaucracy and so we have this contradictory push to increase organ donations while cutting back on transplants.

The medical profession has to engage wholeheartedly in administration. We have to get involved and the way to do that is to decentralise medicine away from the HSE. Put the people delivering the services in charge. That way, transplantation would be run by someone with a track record and commitment to transplant patients and the service would develop to meet the patients’ needs.

WE NEED to dismantle the HSE, not reform it. Four years ago the University of Helsinki Hospital was run by accountants with little interest in patient care, little interest in research and little interest in teaching. In Helsinki they had a vote of no confidence in the board and fired all the administrators. The medical staff took over the hospital and they have 21,000 medical professionals working in the ideal situation.

We too must take responsibility for our vocation. People and medics need to mobilise. The public and private systems need to be totally separate. Private healthcare will always look after itself. Consultants and doctors should not work in both systems. I have seen where the ‘bit here and bit there’ approach ends, and it is always at the expense of the public.

The system should be run by people who care about health, and that is not the HSE. When the Third World is being raided for doctors to fill slots in our system because we can’t keep our doctors here, it’s failing.

Once we have the number of doctors in the country that is required by EU directives, the HSE is satisfied. As long as that numbers box can be ticked, it is satisfied and quality doesn’t matter a damn. This is at every level of our health system.

I don’t know if Leo Varadkar is aware of these problems but I, and all the good guys working in Irish hospitals who care about caring for people, are happy to bring him up to speed.

Our pancreatic transplant unit had one of the highest rates of transplants in Europe and the survival rates were better than the international average. Two years before I retired, I proposed to mentor two registrars who had helped me on pancreatic transplants so that by the time I was gone there would be a seamless transition. My proposal was not even acknowledged, never mind refused.

I retired in January. Within a week, the transplant unit was closed down and patients were left hanging. Would that happen in a system run by people who care about healthcare?

David Hickey performed over 1,500 transplants during his surgical career. He is now director of the National Kidney and Pancreas Transplant Programme