Healthy sys­tem?

Should you feel safe in the Ir­ish health sys­tem?

The Irish Times - Tuesday - Health - - Front Page - Colin Do­herty

Dur­ing the open­ing cer­e­mony of the Lon­don 2012 Olympics, many were moved and de­lighted at the trib­ute paid to the NHS. I re­mem­ber the re­cently ousted head of Ire­land’s health ser­vice, Tony O’Brien, re­mark­ing at the time that his great­est am­bi­tion was to de­velop that sort of de­vo­tion to the HSE. If there were times when he thought he might be mak­ing progress, the last few months and his own fate dur­ing the cer­vi­cal check con­tro­versy ex­tin­guished that hope.

Why is the NHS so close to Bri­tish hearts? A quick re­view of the prob­lems of the NHS re­veals many rea­sons why it shouldn’t be: peren­nial un­der­fund­ing, over­crowd­ing in A&E, sig­nif­i­cant pa­tient safety in­ci­dents and, in a bizarre co­in­ci­dence, a screen­ing pro­gramme er­ror in which half-a-mil­lion women were not called back for mam­mo­grams.

And, yet, the trust and love the Bri­tish pub­lic has for the NHS never wa­vers.

Of course, all of these prob­lems sound ter­ri­bly fa­mil­iar to Ir­ish cit­i­zens and that’s be­cause mod­ern health­care is in cri­sis, not just on these isles but ev­ery­where. And yet, over the sum­mer, if you were to be­lieve the out­rage on dis­play in Oireach­tas com­mit­tees and in the pages of news­pa­pers and on­line blogs and tweets, you would be for­given for be­liev­ing the Ir­ish health sys­tem is at best bro­ken be­yond re­pair and at worst com­plicit in the man­slaugh­ter of Ir­ish women.

In 1991, the Har­vard Prac­tice Study re­vealed that, of nearly three mil­lion ad­mis­sions to New York hos­pi­tals, al­most 100,000 were vic­tims of avoid­able er­ror, 13,000 of whom died due to the harm caused. This gave birth to the pa­tient safety move­ment, which has spread glob­ally.

In Ire­land, the pa­tient safety era dawned mired in the con­tro­versy of missed and de­layed di­ag­no­sis in var­i­ous forms of cancer. Then min­is­ter for health Mary Har­ney, work­ing with of­fi­cials in the De­part­ment of Health, signed the pa­tient safety char­ter in 2010 with full knowl­edge of the bat­tles ahead.

They per­suaded Dr Tom Keane, who had re­or­gan­ised can­cers ser­vices in Canada, to come home to ad­vise on the changes re­quired to im­prove safety and sur­vival. Cen­tral­is­ing cancer ser­vice has saved many lives, but at the time politi­cians saw no down­side to bash­ing the health ser­vice – al­ways tak­ing care not to in­clude the front-line staff, but ex­co­ri­at­ing the “suits” and the “un­ac­count­able man­agers”.

It was the start of a long road of con­fi­dence-bust­ing in Ir­ish health­care.

To be sure, there were many dis­clo­sures of poor prac­tice: Brigid McCole, Susie Long, Áras At­tracta, Leas Cross, Savita Halap­panavar, wait­ing lists for spe­cial­ist treat­ment, the 15-year “cri­sis” in ED over­crowd­ing. What the me­dia and politi­cians failed to see was that such dis­clo­sures were part of the im­proved scru­tiny of med­i­cal care by both the health sys­tem in au­dit­ing it­self, and also by brave and coura­geous cit­i­zens. And yet, progress has been frus­trat­ingly slow and com­men­ta­tors jus­ti­fi­ably search for per­pe­tra­tors of the stag­nant cul­ture; it’s the “civil ser­vants” the “rich con­sul­tants” – some­times the nurses even get blamed.

The fact is, blame is easy, but so­lu­tions are not.

The supreme irony is that the cer­vi­cal screen­ing pro­gramme is al­most the last ser­vice that one would point to as dan­ger­ous or poorly per­form­ing. In the decade or so since its launch, it has saved hun­dreds of lives. And, as I and oth­ers pre­dicted, the Scally re­port did not find the ser­vice to have fallen be­low in­ter­na­tional stan­dards of re­port­ing. While Cer­vi­cal Check and the pa­tients’ doctors were ex­co­ri­ated for the de­lay and meth­ods of disclosure of the au­dit re­sults, it has been over­looked that of the 17 coun­tries in the EU that screen for cer­vi­cal cancer, only 10 do au­dits and only the UK dis­closes re­sults.

Re­cently, in the Bri­tish Med­i­cal Jour­nal, Prof Jef­frey Braith­waite, a world author­ity on health sys­tems de­sign, summed up the prob­lem for health­care in in­dus­tri­alised na­tions: “Only 50-60 per cent of time is care truly ev­i­dence-based, about one-third of medicine is waste or overtreat­ment, and ad­verse events af­fect one in 10 pa­tients and have done so for the past 25 years without sig­nif­i­cant im­prove­ment.” In an ef­fort to ex­plain this, he points out that health­care is the most com­plex thing we do: send­ing rock­ets to the moon does not even come close; each and every pa­tient in­ter­ac­tion has as much com­plex­ity and is at least as po­ten­tially lethal.

There are lit­er­ally mil­lions of health­care in­ter­ac­tions of this sort every year in Ire­land. In the end, Prof Braith­waite’s pre­scrip­tion for change is not to re-draw the or­gan­i­sa­tional chart and fire all the man­agers. In­stead, he asks that we use the ev­i­dence of what works and al­ways use lo­cal so­lu­tions to lo­cal prob­lems: en­gage staff and pa­tients in un­der­stand­ing how to in­ter­act in such a way that the con­tract of care is about love and com­pas­sion, safety and courage, learn­ing and ev­i­dence-based care.

I have been in med­i­cal prac­tice since the Har­vard Prac­tice Study. For the last eight years, I have been work­ing with man­agers and clin­i­cians in the Ir­ish health sys­tem to im­prove care in epilepsy ser­vices. My, al­beit bi­ased, ob­ser­va­tions are that, as a re­sult of this re­newed fo­cus on safety, my prac­tice is al­most un­recog­nis­able from what it was a decade ago: team­work; pa­tient cen­tered­ness (tak­ing pa­tient’s wishes and opin­ions as cen­tral to care); pa­tient safety (record­ing and mit­i­gat­ing er­ror and harm); in­te­grat­ing care across the pri­mary care, com­mu­nity care and hos­pi­tals; con­stantly im­ple­ment­ing new care mod­els and new tech­nol­ogy; and fi­nally, recog­nis­ing that the un­der­served, the poor and the name­less are of­ten dis­pro­por­tion­ately af­fected by poorly per­form­ing ser­vices – this is what our busi­ness is about to­day.

Progress is, of course, painfully slow but it is real.

In May 2018, med­i­cal jour­nal The Lancet pub­lished a large study of ac­cess and qual­ity in the world’s health sys­tems. Ire­land placed 11th of 195 coun­tries – 12 places ahead of the NHS!

In the end, I don’t know if Tony O’Brien’s vi­sion for a health ser­vice that we can all be proud of will ever be re­alised in the minds of our cit­i­zens. I can only speak for my­self as one cit­i­zen who has had the priv­i­lege to work in the Ir­ish sys­tem for 20 years. I am damn proud of it! I am pained by our fail­ures when they hurt our pa­tients, at times em­bar­rassed by in­ef­fi­ciency, frus­trated by the slow­ness of change yet never doubt­ing for a mo­ment the direc­tion we are go­ing and filled with ad­mi­ra­tion for the ef­forts I see around me – from the sim­ple kind­ness of a word of com­fort to the large-scale ef­forts at chang­ing care.

Should you feel safe in the Ir­ish health sys­tem? The an­swer is: you can feel safer to­day than you ever could be­fore but there is much more work to be done; for this we need your help and your sup­port.

– Colin Do­herty is a con­sutant neu­rol­o­gist at St James’s Hos­pi­tal, Dublin, and as­so­ciate pro­fes­sor of clin­i­cal epilepsy, Aca­demic Unit of Neu­rol­ogy, TCD


In May 2018, med­i­cal jour­nal ‘The Lancet’ pub­lished a large study of ac­cess and qual­ity in the world’s health sys­tems. Ire­land placed 11th of 195 coun­tries.

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