View from abroad: How to fix the Irish health service

Ireland’s ailing health service was one of the most contentious topics of the 2016 general election campaign, but it remains to be seen how the incoming government will tackle the myriad problems, from costs to long waiting lists and the number of people on trolleys in emergency departments.

The Irish Times asked Irish healthcare professionals working abroad to share their suggestions for what can be done to improve the Irish health service, based on their experience of better functioning health systems in other countries. Here is what they had to say.

Perth, Australia

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Lisa McGonigle is co-ordinator of Canterbury Community HealthPathways in Christchurch, New Zealand.

Gráinne Ní Shé, intensive care nurse at the Fiona Stanley Hospital

What I see and use in my work on a daily basis are systems, people and processes that are efficient, patient-focused and value healthcare professionals. There is a positive working environment. Staff-to-patient ratios are safe, and support is provided to nurses caring for patients, from clinical nurses in leadership roles such as nurse unit managers, to hospital out-of-hours nurses, medical emergency teams, clinical educators, and a capacity and access service.

There is a good balance between work, family and life commitments for staff. Examples include on-site childcare facilities, daycare centres, vacation care services when children are on school holiday, and family-friendly shifts.

The administration is not top-heavy with managers. There is one unit or ward manager and a nursing director above that person. Irish hospitals have many layers of management.

WA Health recognises the importance of continued learning for the nursing and midwifery professions. Formalised continued professional development, paid study days, and clinical support are offered. There are undergraduate and postgraduate scholarships, and a qualification allowance for postgraduate trained registered nurses and midwives. I am currently in receipt of one of these scholarships as I continue to study for an MSc in clinical nursing.

You never hear about “patients on trolleys”. There is overcrowding in the emergency departments, but the management of this is generally efficient. The introduction of a four-hour rule into three Western Australian tertiary hospital EDs [emergency departments] was followed by fewer deaths and a significant fall in mortality for patients in 2011. This is now the norm in most hospitals. Innovative bed management IT solutions mean nurses know the status of patients and beds at all times, and can manage changes quickly. Nurses in ED are capable of doing more investigations, ordering tests, X-rays, bloods, discharge planning and managing the flow of patients through the ED than in Ireland.

There is no two-tier system. Public and private patients are treated the same throughout the public hospitals.

Community, outpatient and rural services are good. There are services that look after people in their homes to avoid hospital admissions, 24-hour free helpline numbers, and a rural and remote service to look after people in remote areas.

Adelaide, Australia

Dr Toby Gilbert, medical registrar

I was struck when I arrived in Australia four years ago by the presence of doctors as administrators. There are doctors here who have no clinical responsibilities, but oversee the medical running of my hospital. They are involved in systematically maintaining and improving the quality of patient care. In medicine, we call this clinical governance.

Clinical governance asks the question “are we doing a good job?” It measures quality – above and beyond counting patients on trolleys – and helps to direct resources to areas which need it most.

The Royal Australasian College of Medical Administrators is small, with about 800 fellows, but there is no equivalent in Ireland. Taking the population of Ireland in proportion, there would be 125 doctors who could dedicate their careers to ensuring the other 19,000 doctors practise high-quality care.

Queensland, Australia

Dr Iseult Sheehan and Dr Simon Bull, GP registrars

The major issue for patients in Ireland is a shortage of doctors and hospital beds, resulting in longer waiting lists.

Doctors and nurses are trained to the highest standard in Ireland and are sought after worldwide, yet there is a struggle to fill positions; primarily because the working conditions are often appalling.

Several key differences allow for better and faster access to healthcare services in Australia. There are more public rehabilitation (step-down facilities) and nursing home beds, which frees up vital hospital beds. Ireland has a high number of small rural hospitals, but Australia utilises a well-provisioned flying doctor service by helicopter for emergencies in the rural setting, to reduce the number of hospitals required.

In Australia there are more GPs per capita, which allows them to have an expanded role in chronic disease care, thereby reserving specialist clinic appointments for the patients with complicated conditions who really need them.

GPs are also incentivised to do much more procedural work including suturing injuries, skin cancer excision, abscess drainage and applying casts to simple fractures, all of which helps reduce the burden on ED at a huge cost saving to the health service.

Melbourne, Australia

Dr Aifric Boylan, GP

The most striking difference between working as a GP in Australia versus Ireland is that here the health system facilitates me in taking care of patients properly. I can rapidly access diagnostic tests, particularly ultrasound and CT. This often saves referral to the costly hospital system and it is very reassuring to the patient to receive a prompt result.

I can also refer people with mental health difficulties to see a psychologist within their own community, usually within days, and at low or no cost to the patient.

Christchurch, New Zealand

Geraldine McGettigan, Health in All Policies adviser, and Dr Lisa McGonigle, co-ordinator of Canterbury Community HealthPathways

We are two Irish women working in the health sector in Christchurch, New Zealand. We often talk about the differences we see between healthcare in New Zealand and healthcare at home.

Ireland needs a whole-of-system approach to treat the causes of its problems, not the symptoms. We can’t fix overcrowding or waiting lists in isolation, we have to take a step back and figure out why so many people are presenting to ED or waiting to see a specialist in the first place.

Ireland needs a people-centred health system similar to New Zealand’s. Every decision that is made, every plan that is written and every policy that is put in place must focus on and prioritise the people who will use the service, the people of Ireland. In order to create this, the focus needs to shift away from service provision in the hospital and move towards providing more publicly-funded health services in the community.

Irish people should be able to access minor, routine or elective services in their local community without having to travel to a hospital. In New Zealand the motto for their national health target is “better, sooner, more convenient”. The aim is to keep people well in their own homes, through use of publicly funded integrated family healthcare centres, after-hours and community providers.

Here in Canterbury, we can access investigations, diagnostics and acute care such as blood tests, X-rays, ECG, sleep assessment, Pipelle biopsy, MSK injections, spirometry, skin lesion excision, acute medical assessment, minor accident care for broken bones or stitches, and a whole lot more – all at the GP surgery or in another community-based facility.

There is no need to go to a hospital. This reduces pressure on ED and waiting lists and supports the concept of hospitals becoming centres of excellence for specialised care. This shift would require significant investment in upskilling primary care providers and more funding for preventative services.

A people-centred health system requires integrated care and collaboration; all parts of the health system must work together to achieve the goal of a highly functioning health service. Training institutions, unions, professional associations, community care, primary care, secondary care, GPs, doctors, nurses, surgeons, allied health, hospital management, senior HSE management and government must all work together for the common good. There is no room in an effective health system for egos, hierarchy, patch protection or dictatorial management. Everyone must work together to find positive pathways to improvement.

Ireland needs better information systems to facilitate this approach, including secure central medical records which are accessible from multiple sites, patient portals for patients to access their own medical records, and electronic referrals. There must be adequate technology in place to allow a truly modern health system to work efficiently and effectively.

Ireland also needs better health service staffing and infrastructure. There are numerous Irish health facilities which are outdated, too small, no longer fit for purpose and in inaccessible or inappropriate locations.

The solution to this is fewer but newer purpose-built hospitals, which have been designed to meet the needs of modern health service delivery, through a consultative process with staff and patients. For example, before the redevelopment of Burwood Hospital in Christchurch, a design lab was set up where people could walk through mock ups of wards and give feedback on the proposed design of new facilities.

Without the staff to deliver it, there is no health service. Better infrastructure would go some way to giving the frontline staff a better work environment. So would consulting them on important decisions, like hospital location and design.

Ireland has a lot of work to do to improve the morale of its frontline health service staff and can start small. In Canterbury, the weekly chief executive update (which is emailed to all 9,000 CDHB staff, and also available on the public website) keeps staff in the loop about what’s going on, and also contains a “bouquets” section of positive patient feedback. It does wonders for morale and for staff to feel appreciated.

Berkshire, England

Sarah Doran, speech and language therapist with the NHS

In the UK, there are different options to explore before attending an emergency department. If you only require a few stitches or have a sprained wrist, you can attend one of many minor injury centres.

Last Sunday, I woke with a dreadful eye infection at 7am. I phoned the NHS helpline, and within an hour a nurse phoned me back. She listened to my problem, reassured me I didn’t need to see a GP, and provided me with advice on how to manage my infection at home. These services mean less pressure on busy emergency departments.

I provide services to children under the age of five and school-based services for older children. We have received very good feedback on the drop-in clinic we run for preschool children. Parents can access a screening assessment without an appointment, meaning there are no waiting times. We provide advice on the spot, and will refer children for therapy if needed.

The NHS trust I work for also provides mental health services for people in Berkshire which are well advertised and easy to access, including telephone and face- to-face consultations and therapy sessions, group wellbeing courses and online cognitive behavioural therapy support.

Abortion being easily available is also a big positive to healthcare in the UK.

London, England

Naomi Algeo, occupational therapist at University College London Hospital

There’s a growing body of evidence to support the impact that both occupational therapists and physiotherapists have on facilitating quicker and safer discharge of patients from the acute hospital setting. The NHS is really responding to this, despite significant austerity measures across the board, by increasing the presence of therapists in the emergency and acute medical departments. In the long term, it has been shown they reduce hospital stays, prevent re-admission and facilitate independence at home for longer periods of time.

Focus has also shifted towards the patient pathways available following hospital discharge. There are so many options here that can facilitate discharges while also improving long-term patient outcomes. For example, a number of boroughs in London offer “re-ablement” services for up to six weeks, free of charge. This offers patients who may not be back at their baseline in terms of mobility and/or function, to have social service carer input up to four times a day, as well as occupational therapy and physiotherapy. This can facilitate earlier hospital discharges, while also eliminating the need for otherwise inpatient rehabilitation or placement in a residential home.

Generation Emigration is a forum by and for Irish citizens living overseas