Widespread inertia in the health service is leaving Ireland unprepared to cope with a huge increase in the number of stroke patients over the next decade, the outgoing head of the national stroke programme has warned.
In a scathing review of progress in the programme he has led since 2010, Prof Joseph Harbison is strongly critical of resistance to change within the Health Service Executive.
Doctors have encountered “huge problems” progressing the aims of the programme, he says. Having been informed at the outset that implementation was “key” to the success of the programme, they were told by the HSE this was not their responsibility.
Crucial elements of the programme, even those fully supported by HSE management, were frequently ignored at local level, according to his review, seen by The Irish Times. "Like in many organisations, the 'status quo' can be terribly hard to change and 'implementation-free zones' can be encountered, but the status quo in stroke is often very poor and inadequate."
Third biggest killer
Stroke is the third biggest killer of Irish people after heart disease and cancer, and the single biggest cause of severe physical disability. Up to 8,500 people a year suffer a stroke, and more than 800 die from the condition. The incidence of stroke is set to rise by up to 50 per cent over the next decade as the population ages.
Elaborating on his remarks, Prof Harbison told The Irish Times, "No one ever got fired in the HSE for maintaining the status quo. You get in more trouble doing something and screwing up than for doing nothing, which allows you to evade responsibility when things go wrong."
“We realised at a very early point that if we were not willing to implement, to agitate and pressurise people, little would be achieved.” the review says. “With current HSE structures, implementing and managing change is extremely challenging. Even when a plan is in place and resources found, it is our experience it is a mistake to assume that this will automatically happen without continued attention, intervention and agitation.”
It took three years to appoint 40 staff, he points out. “We have even found ourselves resorting to external political pressure to try to persuade hospitals to open stroke units.”
Six out of 27 hospitals have no stroke unit, the review points out. These are also the hospitals with the highest death rates.
Stroke represents a huge and looming challenge for the health service, Prof Harbison says. “We cannot properly cope with the numbers of stroke patients currently requiring treatment. The majority of patients suffering stroke in Ireland still cannot access what would be considered basic care in most developed countries.”
National clinical strategy
A separate national clinical strategy for stroke, such as there is for cancer, is now needed, he believes.
Prof Harbison says that although outcomes have improved substantially since the national stroke programme was developed, they are still worse than in comparable European countries.
“Demographic changes will result in a huge increase in stroke numbers in the next 10 to 15 years. Ireland is currently unprepared for this and I am not aware of any contingency plans in development.”
The existing stroke programme is inadequate to meet the demands of a condition costing the country €1 billion a year, he says.
The existing programme has shown that outcomes can be improved in the absence of resources with effort, reorganisation and a willingness to pull together. “However, there is a point where even innovation and imagination is insufficient. We cannot appropriately discharge patients who still need rehabilitation where there is nobody to provide rehabilitation in the community.
“We cannot expect good outcomes for stroke patients where the basic structures and systems necessary to achieve these are simply absent. These are not problems we can innovate past.”