Opinion: Trust in HSE must be earned from ground up

The HSE keeps getting the basics wrong. It’s time for organisational change, writes Muiris Houston

Vicky Phelan: While we rely on courageous women like Vicky Phelan to stand up to confidentiality clauses in order to reveal the truth in the most tragic circumstances, thousands of Irish people silently suffer HSE ineptitude on a daily basis. Photograph: Collins Courts

The CervicalCheck controversy continues to rumble, developing new threads on an almost daily basis.

Comments from the Taoiseach and Minister for Health suggest they are anticipating further revelations as various inquiries get under way.

But the fundamental issue – failure of communication – continues to be central; other aspects, including those yet to emerge, will likely be peripheral in comparison.

This scandal is primarily about the poor flow of information at a number of levels: a complete absence of information from CervicalCheck to patients who had been screened; impaired flow of knowledge between CervicalCheck and gynaecologists and general practitioners; an astonishing ignorance of open disclosure policy within the health system at senior levels of CervicalCheck management; and, as illustrated by the length of time it took to identify all the women involved, frightening evidence at how disjointed various parts of the Health Service Executive (HSE) has become and how it had such difficulty reconciling basic information within its monolithic structure.


Same errors

One of the most disheartening aspects of the destruction of our public health system is how it repeats the same errors. Whether maternity scandals at Portlaoise and Portiuncula hospitals, delayed cancer investigations leading to the premature death of Susie Long, or in the case of Rebecca O'Malley, a delayed breast cancer diagnosis following the misreading of a biopsy, all share a common thread: poor communication resulting in a failure to share important information with patients in a timely manner.

For all its fine quality improvement initiatives and repeated commitments to patient safety, the HSE continues to get the basics horribly wrong. And while we rely on courageous women like Vicky Phelan to stand up to confidentiality clauses in order to reveal the truth in the most tragic circumstances, thousands of Irish people silently suffer HSE ineptitude on a daily basis.

Here are just a few recent examples: all are relatively low key in the greater scheme of things but telling in that they reveal how the HSE struggles to deliver a basic, uniform standard of care.

An inpatient, admitted and treated for a fractured hip, is referred for a home care package. There is a different form to be filled in depending on the county you live in. The forms differ in complexity, the information required and how they are processed in each locality. In parts of Tipperary, for example, a patient requiring home help must make one application for morning home help hours and a separate one for assistance required in the afternoon. His cousin in east Galway, meanwhile, having got approval for home help, is told that the company contracted to provide a carer in his locality has no available home helps or that there are no resources to cover the cost of his home care. Consistency?

On appealing the decision, the patient and their relatives are told they must make a separate application to a senior HSE manager. When they ask can their original application not be passed up the chain of internal command in the HSE, they are told no, it cannot. Information flow?

Meanwhile, a woman in her 80s who has finished her acute stroke treatment needs a community occupational therapist to assess her need for aids and appliances and to have her home assessed to facilitate discharge. In Kerry, Limerick and Clare, there is a standard referral form. But Galway, Roscommon and Mayo each have separate forms – laid out differently and requiring significantly different levels of information. Uniform standards?

A GP refers a patient to see an ENT surgeon in the nearest acute hospital. The referral letter is returned by a secretary saying there is a four-year waiting list and no further patients are being added. Two simple questions: why were local GPs not informed of this so that they could avoid inappropriate referrals? And why no offer of alternative options from the HSE for the patient caught in the middle?

None of this is rocket science. Yet some 13 years after the HSE was established, this is the level of basic organisational inconsistency faced by sick people on a daily basis.

Doomed to fail

We have heard many promises since the CervicalCheck fiasco broke. All are “top down” changes. Some will create even more layers of management. But without “bottom up” change first, they are doomed to fail.

So here’s a suggestion: pick either a geographic area or a clinical area (as was done with cancer care).

Send in an intervention team from outside the health service with experience in change management and a commitment to structured communication. Take everyday referral pathways, similar to those outlined above, and standardise them. Make communication a simple linear process, with the needs of patients paramount. Include suggestions for improvement from patients and motivated staff (and not just those working in the HSE itself).

Three months later, ask patient safety experts from the Department of Health to visit. Give them one simple objective: establish if information is flowing freely from patient to local doctor to specialist and back to the patient again. Where it's not, say so. Plan unannounced revisit six weeks later. Reward successful implementation. Repeat. And repeat again.

It’s not glamorous. It might be tedious. Some healthcare professionals will feel it’s beneath them. But if we want people to trust the health service again, then this trust must be painstakingly earned from the ground up.

Dr Muiris Houston is The Irish Times health analyst.