SECOND OPINION: THE DOG'S dinner that politicians and the HSE have made of the Roscommon hospital situation is a metaphor for all that is wrong with Irish health services. The sight of Government leaders claiming they cannot keep the full range of services at Roscommon hospital because of the Hiqa (Mallow) report published in April sums it up. They obviously did not read the Ennis (2009) Hiqa report or, if they did, ignored the findings because of the election.
The 2009 report clearly applies to all hospitals of similar size to Ennis, and one of its recommendations is that emergency services should be consolidated in regional centres, with all smaller hospitals redesignated for minor injuries. The Mallow investigation was carried out because the recommendations in the Ennis report had not been implemented and not because each hospital needs its own investigation. In fact, the HSE did not begin to address the safety issues in smaller hospitals until 14 months after the Ennis report was published – and then only after prompting from Hiqa.
None of this is new or rocket science. In 1966, the Irish government produced a White Paper on the development of health services. This paper recognised that a single county is “too small a unit” for hospital services given the increasing complexity of medical care. Further, it stated that a county hospital is not suitable to be “a self-contained unit” and should be amalgamated with teaching and regional hospitals within “a fairly large region”.
Here we are, 45 years later, still resisting the changes required by Hiqa, as if this is all news to us. In the last few days, various vested interests have suggested that this is all about cost-cutting or that Hiqa has an agenda other than safety. This sinister and dangerous development must be thwarted by HSE management.
The Ennis and Mallow reports are crystal clear and very readable for anyone who actually wants to take part in an informed debate. Both reports stress the international evidence, which shows that specific conditions have better outcomes when treated by clinicians who routinely care for high numbers of patients with such conditions.
More staff and resources will not address the problems of the smaller hospitals. For example, the Mallow report showed that the hospital’s three surgeons carry out an average annual total of 50 high complexity surgery procedures, or only one per week. This is obviously not enough to maintain expert skills and is hugely expensive.
The reconfiguration of hospitals did not happen during the days of the old health boards and is only now beginning to happen. There are two reasons for the delay: a lack of forceful leadership within the health services and the ignorance of politicians in relation to health matters. This is obvious when their contributions to the four regional health forums are analysed.
These were set up in 2006 to give effect to Section 42.7 of the Health Act (2004), which allows for public representation and user participation. Each forum has between 29 and 40 members representing city and county councils in the region. Members of the forum make representations to the HSE on health service needs and the executive provides administrative support. Meetings are held six times a year and members also meet during the year in various committees.
These forums are an opportunity for politicians to influence health services for the whole region, but their contributions are almost invariably about local hospitals or the needs of individual service users. Debates are often little better than bull sessions. Councillors show very little understanding or interest in the wider dimensions of health, which they have the power to influence but seldom do.
Local authorities and politicians should be aware that about 80 per cent of what creates health – such as employment, housing, food availability and the environment – is in their hands, but they do not seem to make the connection. For example, Galway City Council has just rezoned almost 10 acres of land which paves the way for a new hypermarket. These can create food deserts because they push out local shops, which are important to every community.
Politicians should be seeking health impact assessments on all new developments in their local authority area. They rarely do that and instead engage in parish pump politics as is obvious from their contribution to the health forums. We will never manage to reform the Irish health system until politicians educate themselves about health matters and HSE managers assert themselves forcefully when changes have to be made.
Dr Jacky Jones is a former regional manager of health promotion with the HSE