Truly patient-centred health service demands harsh medicine

The politics of Irish healthcare is reminiscent of the “tragedy of the commons”, a concept that can be traced back to the 19th century economist William Lloyd. He used it to describe how individuals who shared resources – in his case grazing land – act in their own self-interest to the ultimate detriment of all.

There is much to think about here for doctors who are embracing the evolving concept of professionalism which mandates that we consider broader societal needs and not just those of any single individual or cohort. I would argue, furthermore, that those of us in positions of leadership in healthcare have an ethical duty to articulate some challenging truths if we are ever to have a health service that can meet society’s needs.

The never-ending series of resource and governance-related scandals within our health services – trolley counts, lack of investment in primary care and mental health, and retention of healthcare professionals – all attest to our inability to resource or organise any one particular service adequately.

Many of these issues occur because the system persistently underfunds duplicated and fragmented services, sometimes because of pressure from public representatives and local communities. This is particularly the case for acute care, a completely unsustainable fragmented system.

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There is ample evidence that critically ill patients have better outcomes when treated in high volume centres under the care of experienced multi-disciplinary teams. Yet, as the Roscommon Hospital experience shows, evidence-based arguments can struggle to cut through when well meaning local concerns are amplified by politicians and campaigners.

The argument for redesign of our hospital networks is a critical imperative in light of the demographic time bomb facing this country

The hospital closed its accident and emergency department in 2011 in the teeth of local opposition. We now have the benefit of hindsight with Roscommon, however, and it is clear that the appropriate structuring of smaller hospitals can allow those hospitals to thrive and provide an excellent and appropriate service. More surgeries take place every day at Roscommon now than ever before, and it has an exciting future as a day-case surgical facility for the people in the region.

Local communities

I understand the challenge this argument presents for public representatives and local communities. The reality at present, however, is that acute surgical services are delivered in 26 hospitals in Ireland, half of which cannot be staffed at either consultant or non-consultant level.

The recent comments from the president of the High Court when he admonished the HSE for employing junior doctors without adequate vetting for appropriate competence are very relevant here. We are in this situation because Irish-trained doctors will not work in smaller units that cannot provide comprehensive care to critically ill patients, and hence can never provide them with the opportunities they need to maintain their skills and advance their careers.

The argument for redesign of our hospital networks is a critical imperative in light of the demographic time bomb facing this country. Demand for health services is going to continue to increase because of our aging population. Despite efficiency improvements of about 20 per cent over the last six years within surgery, my own speciality, waiting lists continue to grow, and trolley wait times are persistently unacceptable.

At present we discharge 170,000 surgical inpatients annually. By 2050 this will have increased to 270,000. Over 50 per cent of the population will be aged 65 or older.

As older surgical patients spend longer in hospital, an additional one million bed days annually will be required. This is the equivalent to an additional 10 medium-sized hospitals. Non-surgical medical specialities face even greater challenges.

Clearly hospital expansion on this magnitude will not happen, nor should it because redesigning the existing network could go quite some way to dealing with our population changes, and our resource and workforce requirements.

Sláintecare, with all-party Oireachtas support, represents at the very least an attempt to articulate a vision for our healthcare system. We must embrace it as a prism through which healthcare professionals, patients and politicians can have a serious and long overdue conversation about the type of health service we want to have.

To be clear, this is not all about more money, notwithstanding the reality that some services do require greater funding

That conversation must be based on a shared understanding that if we are to ever have a truly patient-centred health service we will all need to swallow some unpalatable medicine regarding healthcare resource allocation.

Opportunity

To be clear, this is not all about more money, notwithstanding the reality that some services do require greater funding. If, however, we miss this opportunity to redesign our acute services and fully integrate community, primary and hospital care, and if we continue to pour more money into an inefficient, badly organised system, we will condemn ourselves to everlasting discord within our health services.

The Royal College of Surgeons in Ireland would welcome the opportunity to contribute to a forum allowing an informed discussion with patients, their public representatives and our health service administration in addressing the challenges in our health services, and finding a way out of the maze that we find ourselves in.

Kenneth Mealy MD FRCSI is president of the Royal College of Surgeons in Ireland