Broken: Ireland’s ailing health service
Sick system, part 1 of a series on Ireland's ailing health service.
Of the many places from which to observe the Irish health service, the flat of your back is one of the worst. Too often at this moment, when patients are at their most vulnerable, the system lets them down.
It certainly failed Rose O’Halloran. The 101-year-old spent more than 24 hours trapped on a trolley at the Adelaide and Meath Hospital, in Tallaght, on the Monday of the June bank holiday.
Born before the Easter Rising that paved the way for this country’s independence, O’Halloran lived long enough to endure the indignity of queueing overnight in the crowded confines of an emergency department because a bed could not be found for her.
It was, as staff later said, a form of “torture” and “a human rights abuse”, one served up by a state that has had almost a century to get these things right.
At least O’Halloran eventually got the treatment she needed. In Portlaoise and other towns, babies have been dying or suffering disablement in maternity units in circumstances that vary from questionable to downright wrong. No one would have learned of this but for the valiant efforts of parents to establish the truth.
It has been a bad year for the health service. Bottlenecks, the kind experienced by Rose O’Halloran, have created enormous queues for treatment. Critical reports on maternity services, nursing homes and care homes for the disabled paint a sorry picture of substandard care and mistreatment of patients and residents.
Dispirited staff are voting with their feet, moving to countries where the pay as well as the working conditions are better.
At the top, many of the major plans for reform are on hold and there is a constant churn of senior managerial positions.
The new Minister for Health, Leo Varadkar, has been active and energetic, with more money to spend than his predecessor, James Reilly. But he has yet to get to grips with the huge problems besetting the service. With an election in the offing, Varadkar’s interventions are of a stopgap nature.
The ship sails on, of course. People fall sick and many get a pretty good service once they get into hospital. That, however, is not the point. We pay vast sums for our health service – almost €13 billion a year. We educate some of the best doctors and nurses in the world. We don’t do this to create a mediocre system, one where it takes years to be treated, one that is crumbling before our eyes. We deserve better.
“Better” seems a distant prospect. Long waits mean patients are denied meaningful care. The healthcare system is riven by conflicting interests and proposals for reform. The system, increasingly bereft of qualified staff and constipated with demand, is one bad winter away from breakdown.
Mystery of the missing trolleys
The trolley crisis encapsulates the system’s deep-seated problems. Every month the Health Service Executive collects hundreds of pages of data on every aspect of performance in the health service, from absenteeism among nurses in the midlands to agency pay in the palliative-care division.
Strangely, the metrics that people really care about, such as daily trolley numbers and waiting lists for scans, are not published. It is left up to the Irish Nurses and Midwives Organisation to publish figures on the numbers waiting daily for admission to hospital.
These figures tell their own story. Trolley numbers peaked at a record high of 601 on a single day last January, making a mockery of a 2011 promise by the Government that a then peak of 567 trolleys would never be exceeded. Back in 2006, as minister for health, Mary Harney declared a national emergency when the number hit 495.
Emergency taskforces have come and gone. Tens of millions of euro have been thrown at the problem. Yet the figures are worse than ever. As I write these words, on a benign end-of-summer day, 366 patients are on trolleys, including 52 at Beaumont Hospital and 30 in the same corridors in Tallaght where Rose O’Halloran lay. In August they were 40 per cent up on the same month last year.
The figures for inpatient and outpatient waiting lists are hardly better. By midyear 414,000 people were on the outpatient waiting list, including 85,000 waiting for more than a year. Last month inroads were made into the long lists, but only by throwing money at the private sector to see and treat patients. The last time this was tried, in 2011, the success was short lived, and the lists grew again once the initiative ended.
In April thousands of X-rays were reviewed and hundreds of patients recalled in seven hospitals after errors were discovered. Separately, questions were raised about hundreds of colonoscopies performed at Wexford General Hospital.
Who, or what, is to blame for this? The most obvious culprits are the cutbacks imposed on health during the economic downturn. Health spending soared during the long years of the boom – up 70 per cent in real terms between 1997 and 2002 – then fell back 16 per cent between 2009 and 2014. We’re back now at the level of spending seen a decade ago.
Reports suggest that what can be cut has been cut. Some pruning was feasible, even necessary, but the low-hanging fruit has been picked. The Minister for Health says he needs at least €1 billion to revive the system; the HSE says it requires an additional €2 billion.
Why we need a joined-up service
Yet many of the problems of the health service have little to do with money. Hundreds of consultant posts and dozens of GP places remain unfilled despite funding being in place. And there is certainly no financial explanation for the rudeness meted out to some of the women in the Portlaoise scandal – “We were treated with disdain. They hated us,” Róisín Molloy recalled.
Funding is invariably found when needed, whether for pet projects – free GP care for under-sixes, for example – or in response to a crisis.
The demand for healthcare is so great, and the cost of providing it is rising so fast, that no country is capable of meeting all needs. Healthcare costs everywhere threaten to bust national budgets, as innovative new drugs and treatments come at an enormous price. Some rationing is inevitable. If extra money does become available, the challenge will be to spend it wisely and not to bow to the demands of vested interests.
Healthcare is a complex process involving many actors. Some care can be scheduled in advance; other treatments are provided in an emergency. Collaboration, both within teams of professionals and across professions, is vital. So, too, is a continuous process of review and cross-checking, to ensure that standards are maintained and mistakes minimised.
The Irish health system struggles to provide this joined-up service. We don’t measure things enough, and even when we do we don’t publish enough of the most important data. We don’t compare the performance of different parts of the system enough.
We don’t reward excellence. We don’t publish meaningful information to allow patients assess the quality of services. Vested interests are too powerful and politics rife. So, too, are rivalries between clinicians and managers, and between doctors, nurses and other professions.
We admit sick patients but are unable to find beds for them. We tell other patients they are well enough to leave hospital but can’t discharge them because there isn’t enough stepdown care.
We force patients to wait years for vital operations, then cancel them at a day’s notice because of staff shortages. We route patients into expensive emergency departments because primary care is so underdeveloped.
We deny patients vital treatments on financial grounds – gastric-band surgery, for example – without factoring in the cost of treating them later.
We allow skilled staff to retire without considering who will take up the slack. Witness the recent fiasco surrounding the suspension of the State’s only pancreas-transplantation programme.
Ghoulish HSE refuses to die
It can’t go on like this. Recent years have been a constant churn of senior managerial positions in the HSE. Recruitment for the new hospital boards, touted as the latest panacea for the ailments of the system, has proceeded at a snail’s pace.
The HSE itself, which was supposed to have been abolished, lives on as a ghoulish creature that refuses to die, despite being universally reviled as the scapegoat for the problems in the system.
Every year another 25,000 citizens turn 65. The challenge posed by lifestyle diseases such as obesity and diabetes grows, and the cost of novel treatments for cancer and other diseases threatens to consume huge chunks of the budget.
Staff are abandoning the health service for better pay and conditions in Australia, Canada and the UK. The system is increasingly staffed by temporary and agency workers on short-term contracts, unfamiliar with their working environment, often overeager to order tests, unwilling to take decisions independently. Money is an issue, but what seem to tip many over the edge are the chaos and uncertainty.
With an election in the offing, health will be a major battleground between the political parties. The final touches are being put to elaborate sections on health in party manifestos, no doubt involving lavish promises of the kind made during the last election.
Money will be thrown at the system to effect temporary solutions to the problems. And the cycle will repeat itself – unless there are radical changes.
Infections: Where the health service gets it right
Ditching the soap and water might seem an unusual approach for improving hospital standards, but it has worked for the Irish health service. Rates of hospital-acquired infections have more than halved over the past decade, and one reason is a switch to alcohol gels for washing hands.
This was just one element of a concerted effort by the system to reduce such infections. It shows how joined-up thinking, strong leadership, commitment from staff and realistic funding can make a difference.
When doctors and managers are freed from political constraints and act decisively, the results can be impressive. Consider the consolidation of cancer services and improvements in survival rates, dramatic strides in the management of stroke patients, and reduced overcrowding in the emergency departments of St Luke’s in Kilkenny or St James’s in Dublin.
The pity is that such initiatives are rare.
It is hard now to explain just how bad things were a decade ago, when infections caused by antibiotic-resistant superbugs were widespread. Patients went into hospital with one illness and end up with a more serious one.
The superbugs haven’t gone away, but they are being contained. The proportion of Staphylococcus aureus infections that are resistant to antibiotics, for example, has dropped from 42 per cent in 2004-2006, to less than 20 per cent last year. “It’s a good example of how a consistent focus on a problem can lead to lasting improvements,” says Dr Rob Cunney, consultant microbiologist with the Health Protection Surveillance Centre and the HSE’s clinical lead on hospital-acquired infections.
There’s still a lot to do. We still only rank “moderate to high” internationally for MRSA rates, he says. In particular, infection control outside hospitals, such as in nursing homes, needs to be improved.
How I see the health service: The doctor
“Dr P”, a respected consultant at a large teaching hospital, says he is “sick to the back teeth” with the frustrations of working in the health service. He describes a system where patients are deliberately misled, red tape impedes doctors, and standards are slipping.
While Dr P’s views wouldn’t be shared by everyone working in the health service, they are reflective of widespread disillusionment among key staff.
“It’s soul-destroying,” he says. “The whole system is grinding to a halt. The doctor is the least important person working in a hospital these days.”
He enumerates the many indignities that doctors in his hospital endure: pleading with the purchasing department for essential theatre equipment; having to communicate with 2,000 patients with just a share of a secretary, when senior managers have two; not being able to operate on three out of four patients on his list because of a shortage of beds.
He makes allegations of sharp practice. During the peak of the winter overcrowding crisis, he claims, one hospital moved patients waiting for admission into secluded parts of the building so they wouldn’t figure in the daily trolley count.
“The system has become a self-serving bureaucracy,” he says.
The best doctors are leaving, voting with their feet in response to pay cuts in recent years, Dr P says. “How many internationally renowned surgeons are there in Ireland any more? When your colleagues are not up to the job, your own life gets harder and harder because you’re making up for them.
“So you tell patients, ‘There’s nothing I can do for you,’ when you should be saying, ‘We can’t get the right person to treat you.’ To be honest I’m sick of fighting for patients. I used to fight tooth and nail when they said they had no beds. Now I just accept it.”
How I see the health service: The advocate
“It depends on the timescale,” Sheila O’Connor of Patient Focus says when asked how the health service is doing. “Compared to 20 years ago it’s got much better. More recently it hasn’t been doing so well. It’s sad that nothing gets done, still, unless there is a huge patient outcry.”
Recent decades have been a period of enormous transition, not just in services but also in the underlying culture of the health service, she says. “In the past health was something done to people. That ethos is no longer acceptable, though it still exists in some areas. People are not passive recipients of healthcare, not any more.”
The handling of patient complaints has improved, partly thanks to reports by the Health Information and Quality Authority. “Back in the 1990s hospitals couldn’t even bring themselves to refer to complaints from patients, much less handle them properly. They’d refer to the ‘patient liaison service’ rather than admit people might have complaints worthy of investigation.”
Patient Focus, which grew out of the Michael Neary scandal 20 years ago, played a key role in supporting the parents who lost babies at Portlaoise hospital.
A common thread joins these episodes: “Damaged patients felt they were placed in corners and forgotten about,” O’Connor told a Dáil committee earlier this year. Patients were “treated as an embarrassment by the very people and institutions supposedly tasked with their care”.
Despite improvements, patients still experience difficulties getting their records from hospitals or individual doctors, she says. Other problems include a lack of communication and “paternalistic attitudes” on the part of doctors or nurses.
O’Connor believes parts of the health service are still delivering an old-fashioned “maintenance model” of care. “We have a long way to go.”
How I see the health service: The patient
Mauro Zelli, from Kilkenny, is just one of the tens of thousands of people being failed by the Irish health service. His daughter Claudia contacted ‘The Irish Times’ in frustration after being told his much- needed cataract operation won’t happen for another 16 months.
After an eight-month wait, Zelli, who is 72, received cataract surgery on his first eye last November. His daughter says he was told that surgery on the second eye would take place within six weeks. Since then the sight in his second eye has deteriorated, but the waiting time at the hospital has grown.
“We have phoned on numerous occasions, being told the waiting list was three months, then nine months and then 16 months,” she says. “It is very frustrating. I think for my parents it’s nothing new, so the frustration isn’t quite as intense as it is for me.
“I live in Spain, so when I come back to find my dad with no sight and pain in his eye, only to be told he’s not on an urgent list so the wait is now 16 months . . . I mean, it’s a ridiculous length of time for a very short procedure.”
She’s been told there’s a chance Zelli could be seen faster if he goes for a check-up separately to report the deterioration, but first the hospital has to send on information about the first operation to his GP. This hasn’t happened yet. “I’d imagine there are many people in a similar position, so I don’t know if it will change anything. It’s all another waiting game.”
Claudia Zelli acknowledges thousands of others are in the same situation, “not deemed ‘urgent’ enough to receive the gift of sight”, but this comes as little comfort.
Thousands of operations on the Waterford lists have been outsourced to private consultants over the past month. This won’t benefit Zelli, as it applies only to patients waiting more than 18 months.