I got to thinking recently about how I would go about explaining to a visiting stranger how our healthcare services are organized and governed, writes Denis Doherty.
The short, perhaps cynical, answer might be that, like Topsy, they just “growed”. That sort of flippant answer would at least serve the purpose of explaining that ours is not a healthcare system that lends itself to being replicated elsewhere. Nevertheless it works well in most important respects and our healthcare workers are very well trained, qualified and committed to their work.
That said, imagine trying to explain that some of our acute care hospitals are public, some are private and still others are public voluntary. Some private hospitals are co-located with public voluntary hospitals. Almost half of our population hold private health insurance and some people opt to avail of the services of a private hospital when required and meet the costs involved directly. Policy is to discontinue private practice by consultants in public hospitals and is currently being implemented.
Fragmentation is a problem, in areas of ownership, accountability, and sometimes imbalance between provider priorities over user needs considerations.
By now the visiting stranger is likely to have lost interest and switched off. But wait, visitors tend to interest themselves in newspaper, radio and television coverage of local news while they’re here. So far this year they would be left with a very poor impression of our health services.
The word ‘insourcing’ would have created interest and curiosity. Discovering that insourcing could accommodate arrangements whereby health services employees were also company owners/directors and service providers to their employers without apparently giving rise to any moral, ethical, governance or accountability concerns would surely have been a source of puzzlement to them.
In the paediatric surgical area alone, there have been allegations of unauthorised devices having been implanted in patients and of patients having been subjected to surgical procedures that were unnecessary.
I watched the televised parliamentary proceedings that dealt with issues at the Child Health Ireland (CHI) hospitals. A member of the committee, who is also a medical doctor, called for the resignations of the CHI Board and its managers. Remarkably, he didn’t suggest that any steps be taken against any consultant doctor whose behaviour was found to give rise to the controversies.
A dispute concerning the refusal of CHI to disclose information requested by the organisation’s funder rumbles on and even if it is, as claimed, on legal advice, it raises fundamental concerns not just about relationships but about the adequacy of the arrangements in place for accounting for the use of public funds.
The combination of controversies involving CHI and the lengthy time and financial overruns of the new children’s hospital are unwelcome distractions at a time when the prospect of the opening of such a significant new hospital service ought to be a greatly anticipated event, instilling confidence that the children most in need of top class hospital will finally have one. The losses experienced by children and families due to the inordinate delays experienced in completing this project can never be repaid.
Try explaining what the roles of Section 38 organisations and Section 39 organisations are, how they’re funded and held to account and don’t be surprised when eyes quickly glaze over. The fact is they are vital cogs in health care delivery here.
On the other hand, play a recording of the RTE programme that exposed the gross mistreatment of residents of three nursing homes and observe how quickly looks of horror and disbelief are seen. It will give rise to incredulity that staff employed to care for vulnerable older people could behave so very uncaringly, that there were such staff shortages and that the provider of services in the homes concerned adopted such a detached, if formally apologetic, position in relation to their failure to meet their obligations to vulnerable older people entrusted to their care and for which they were very well paid. The role of the regulator of the sector clearly needs to be strengthened.
Try explaining the rounds many young people in need of mental health services support, and their families, must endure and observe the puzzled looks you receive. Try explaining why accessing a general medical practitioner appointment as a private patient or as a public patient can involve a wait of over a week when the Sláintecare Report, published over eight years ago, proposed that most healthcare should be provided in the community.
The Sláintecare Report correctly emphasises the importance of strong clinical governance in our health services. That’s not enough though. Strong governance across all of our health services is essential. Codes of Ethics and Conduct across all areas of health care delivery are urgently needed also.
The risk of economic turbulence in the years ahead will necessitate stronger cost control management and more nimble responses to financial shocks to the system than we are accustomed to.
It is government policy to have clear separation between public and private medical practice. That arrangement works best in times of economic prosperity and can change very quickly in the event of an economic downturn that puts private health insurance beyond the reach of many existing privately insured individuals and families. In that event, the public system will be required to scale up to meet the increased demand.
Experience to date would suggest that healthcare ought to be regulated by a single, government appointed, entity that would set and enforce governance, ethical, and behavioral standards across the entire healthcare delivery system. The National Authority would set the overall standards and license sectorial regulators to implement the prescribed standards. A version of advice often proffered by George Bain, the very wise former Vice Chancellor of Queens University of Belfast, would be that ‘the National Authority would be responsible for watching the sea while the other authorities would be responsible for watching the waves’.
The aim of the regulatory framework ought to be that of ensuring compliance with prescribed standards across the entire healthcare delivery system, promote uniformly high standards of care and reduce the volume of negligence claims thereby producing cost savings and expand service user satisfaction levels.
That is but step one. The task of transitioning from what currently passes for a workable healthcare system to a modern fit for purpose one, based on meeting the needs of all our people, in a timely manner, at the lowest level of complexity in keeping with the best available in other EU member states will be onerous. It will require commitment, courage, funding at the top level of what can be afforded and the imposition of standards that are well communicated and enforced to the extent necessary to afford users confidence they will receive high quality services when they require them.
Approaching problems the way we always have done and expect different results is not an option!
