For the sixth year in a row pre-budget political tensions and pubic dismay at the announced “hits”crystalise a central challenge for Irish society: how to provide decent public services in an affordable manner.
Is there a better way to resolve this dilemma than by continuing to cut services and increase the cost? Is there a smarter way?
Five years ago Harvard professor Clayton Christensen presciently remarked: "Healthcare is a terminal illness for America's governments and businesses. We are in big trouble".
Just weeks ago this still unresolved healthcare crisis threatened the very capacity of the US to govern itself effectively. He might well have been speaking of Ireland. We too are in big trouble over healthcare.
Christensen famously coined the term "disruptive innovation" to describe a type of innovation that has revolutionised many industries, such as phones, air travel and computers, making products and services more affordable and accessible to everyone, and not just rich people. In The Innovator's Prescription (2009) he applied his ideas to healthcare systems, distinguishing three types of ailment.
It is impossible to summarise the book here, but a mundane illustration may help: I had a flat tyre recently and instead of leaving it in a high-tech workshop as if I had crashed the car I drove straight into Advance Pitstop and was out in 20 minutes with the tyre fixed for €15. lllnesses for which medical advances can now provide a definitive diagnosis and specify an effective remedy may be routinised and treated in specialised centres, analogous to Advance Pitstop, such as eye surgery clinics or heart centres, instead of being bundled in with more complex cases in a large general hospital, which is ultimately a highly inefficient arrangement that delivers suboptimal care.
An example is the vascular surgery unit in the Galway Clinic. At a conference in Trinity College two years ago, Niamh Hynes of the clinic set out a compelling case for separating out from general hospitals and streamlining procedures that can more or less be routinised.
Her comparison of the cost and quality of the clinic's services versus similar services provided by University College Hospital, Galway, were truly remarkable. For example, "cost per any procedure" was €22,850 in UCHG and €6,455 in the clinic. More importantly Hynes reported superior outcomes for patients, which generally happens when clinicians work on the same problem repeatedly.
The second category of health problem which Christensen suggests requires the expertise of a "solution shop" in healthcare, meaning a fully equipped hospital or multidisciplinary team. This area includes more complex cases like car crash victims or difficult-to- diagnose illnesses where intuition and trial-and-error by very experienced clinicians and other professionals offer the best prospects.
The third category , and the area of highest cost to health and social services and greatest human suffering, is the care of people with chronic diseases or enduring disability which require a service delivery model that Christensen calls a “facilitated network” which in essence is a network of providers – family members, volunteers, GPs, other health professionals, sports clubs and and others depending on the person’s needs. The most cost-effective care system for most people with a disability or chronic illness is in the community, not a hospital or a type of “home”.
In Ireland we have many remarkable success stories of facilitated networks, such as the well-known work of Genio who, with State and philanthropic support, have supported the movement of people from institutions to personalised solutions in the community, resulting in cost reductions averaging 25-30 per cent and, crucially, better quality of life for the people concerned.
Genio projects, including a really exciting initiative on managing dementia in the community, constitute at this stage “islands of innovation” which have the potential to be replicated across the whole country.
Disruptive innovation is well named because it disrupts all elements of inherited service models, particularly professional demarcations and power structures, and other deeply embedded elements of the established formula, like the location in which the work is done and the funding model. In his "Smarter Society" article last Saturday, Carl O'Brien illustrated the almost limitless scope to apply this thinking to other services, with examples of how health, prisons, social welfare and education are organised in other countries, and poignantly asking "why can't we be like these guys?"
It is possible to deliver quality public services much more cost-effectively, but not simply by cutting staff and paying people less to work longer hours, mostly in the traditional way and in inherited structures, which is the essence of the Croke Park and Haddington Road deals.
Nor will privatisation of services “per se” do it. Cutting pay and increasing working hours, although painful, is a relatively simple administrative task. Disruptive innovation, which entails radical service reconfiguration and deep cultural reform, will require expertise in managing complex change and courageous leadership by all interested groups. It will not all come down to James Reilly .
The good news is that many official policies and initiatives already under way augur well for this kind of transformation, such as disability policy and the roll-out of clinical programmes in the HSE.
But game-changing systemic reform takes time, five to 10 years, and perhaps Dr Reilly's biggest failing has been that of every politician, to overpromise and underdeliver instead of the opposite.
Eddie Molloy PhD is chairman of Mental Health Reform