Patient needs must drive health reform

The tussle between quality of care and cost reduction is at the heart of health service reforms, the fourth Pfizer ‘Irish Times’ healthcare debate was told

ATTEMPTS TO reform the delivery of health services have largely been resisted but the status quo cannot continue in Irish hospitals, a consultant surgeon has said.

Finbar Lennon, of Our Lady of Lourdes Hospital in Drogheda, said people wanted some form of health service reorganisation and that change, for better or worse, was inevitable.

“Most people working in the acute hospital system know it is broken,” he said.

“It is not broken in the sense that care is not delivered. It is broken in the sense that care is often ineffective, unavailable to many, sometimes unsafe and too expensive.”

Speaking during the fourth Pfizer Irish Timeshealthcare debate, held at Dundalk Institute of Technology last week, Mr Lennon said hospital reform had generated impassioned debate for decades and people still had hugely different views on how it should be implemented.

“The central objective of hospital reform for doctors and nurses is to make changes that will improve the quality of patient care,” he said.

“The central objective of hospital reform for managers and politicians, however, is cost reduction. The current clamour and turmoil in the healthcare debate is because these two positions seem poles apart.”

The debate on the motion, “This house agrees that hospital reform and reconfiguration is necessary and inevitable”, was attended by about 100 people from across the northeast.

There has been strong opposition to Health Service Executive (HSE) plans to withdraw services from local hospitals and centralise them in larger facilities in the northeast.

Mr Lennon, supporting the motion, said discussion of healthcare reform consistently generated public concern and scepticism and that prescriptive solutions to such problems generally failed.

“A good authority first harnesses consensus for change and then listens and responds. You must listen not only to those who agree with you but more importantly to those who do not . . . The true reformers are often in the latter group.”

He said there had been progress in the provision of services in the northeast but that “reform will take time and years to complete”.

Marie O’Connor, a journalist and member of the Health Services Action Group, said health services in the region had been ravaged and reform was converting local facilities into glorified nursing homes.

Ms O’Connor, opposing the motion, said HSE plans to take 5,000 public patient beds out of the health system over the next five years would eliminate all non-specialist hospitals and funnel AE services into huge “Tesco-style” hospitals.

“There is no good evidence that patients do better in larger hospitals,” she said. “People will die for the want of appropriate care in the community if this plan is implemented.”

The Hanley Report, which was driving HSE reform, Ms O’Connor added, proposed a 2,400sq mile catchment area and a population of up to 500,000 people for a viable casualty unit.

Some people could live two hours from an AE department, she said, and paramedics, touted as the solution to bridging the distance, had expressed concerns about treating seriously ill patients in the back of an ambulance for hours.

Ms O’Connor went on to say that privatisation was the “hidden heart” of HSE reform. “Only by cutting public hospital inpatient services, that are free of charge for the entire population, can you create the market for fee-paying services.”

Dr Colm Quigley, a physician and adviser to the HSE northeast transformation programme, said hospital reform was driven to ensure patients received the best possible quality of care.

Dr Quigley, in favour of the motion, said patient safety must be at the heart of healthcare and reform ensured patients got the best treatment from the most qualified medics.

“It would be simply poor generalship to disperse all your forces over a wide area and ending up losing a battle,” he said.

“We have to concentrate our resources against the foes of ill health, cancer and other illness by concentrating our knowledge, experience and resources into larger centres so we can win these battles like any good general would try to do.”

Dr Quigley said reconfiguration would happen across the wider health services as it was “the right way to do things to have highly trained staff together sharing collective knowledge and experience in the one place where they could provide, in a cost effective way, the best results for patients”.

He pointed out that medical practitioners across the State had put themselves forward to help reconfigure the hospital system as they believed it was “not about saving money, but about freeing money to invest elsewhere to get better health value for all our patients”.

“It is in the interest of all our people and local communities to focus on patients, not buildings or places . . . If we fail to reconfigure, we will fail all our patients,” Dr Quigley said.

Dr Bill Tormey, a consultant chemical pathologist at Beaumont Hospital in Dublin, said the debate would not be taking place if “there was not a problem in this country with secrecy and bullying”, which meant people did not know what was happening in the health service.

Opposing the motion, Dr Tormey said Irish people were naturally suspicious of what was taking place in hospitals and opposed the health service telling them what was best.

“There are so many people in the audience here because they are suspicious of what is going on and why it’s going on,” he said. “I respect Joe Public and on this occasion Joe Public was never asked.”

Dr Tormey said “notoriously in medicine the northeastern health board has been a joke”, and that the Teamwork action plan to reconfigure services in the region ignored a culture of secrecy and the consequences of the Consultant Common Contract, which meant practitioners could not speak out without consent from their employer.

He said patients died in hospitals regularly, because of intervention in the disease process, and this fact should be better communicated to the public and between medical practitioners.

“The curse for this area, from an outside point of view, has always been the failure of medical communication to each other and respect for one another’s areas of competence.

“If you have a patient in front of you and you know that such and such a doctor is miles better at this you are obliged under medical ethics to pass that patient on as soon as you can.”

The debate opened to the audience following the contributions of the four panellists.

Anne Campbell, a local journalist who is eight months pregnant, said she intended to pay to have her baby in Newry rather than risking going to Our Lady of Lourdes Hospital in Drogheda, where there had been a series of maternity scandals.

In response, Dr Quigley said unfavourable reports about the hospital were being addressed and that there was “absolute commitment” to change, but that this would take time.

Ms O’Connor said maternity services in Drogheda were overstretched by 40 per cent and that centralising the region’s maternity care in the hospital would exacerbate the problem.

Another audience member, Joe McGrath, a consultant surgeon at Navan Hospital, asked why there was such difficulty in implementing changes in the health service, as proposals recommended more than three years beforehand for his place of work were not yet in place.

Mr Lennon said communication among medical practitioners was a huge issue and conceded that there was no point having prescriptive solutions if they were not executed.

He stressed many recommendations relating to hospitals in the region had been, or were in the process of being, put in place and that local consultants were committed to change.

Dr Tormey noted Mr Lennon’s acknowledgement that there was a problem with dialogue in the area’s health service as “extremely telling”.

In summation, the debate chairman, Irish Timesassistant editor Fintan O'Toole, said there was wide agreement among the panel that health reform had to be driven by patient needs and that communication levels should be improved.

He said there were mixed views as to whether smaller or larger facilities would offer better patient care and as to how pivotal a role privatisation would play in medical care in the future.

When asked if they agreed with or opposed the motion, the audience showed even support for both arguments, prompting Mr O’Toole to declare the debate a draw.