HEART BEAT:Even the lip service normally paid to medical education has been forgotten writes MAURICE NELIGAN
LAST WEEK, I managed to avoid mentioning the health service at all. But the trolleys refuse to go away – in fact they seem to multiply. The response from the Minister and the functionaries of the HSE is to pretend that this is not happening.
The situation is so dysfunctional, disorganised and contradictory, that it is difficult to know where to start writing about the problems. Let me start by writing about the difficulties currently facing the Non-Consultant Hospital Doctors (NCHDs). All doctors practising in the State, in whatever aspect of medicine, have the experience of being, or having been, an NCHD.
The intern year, the first after qualification, is obligatory for all and a prerequisite to enrolment on the Medical Register. For a few doctors this is the only experience of hospital medicine. For the majority however their period in hospital medicine or, as we would put it, in training, extends over a longer period.
Oliver Wendell Holmes (Snr), author, poet and physician, wrote that “the bedside is always the true centre of medical teaching”. Sir William Osler taught that “postgraduate study has always been a feature of our profession”.
The Irish School of Medicine honoured these precepts and their teaching hospitals justly acquired great repute. Medical education was a duty and responsibility for those leading the profession.
Many young doctors came from overseas to learn here and to return to their own countries to practice, bringing with them the knowledge and skills learned here. As a byproduct of this, the reputation of Irish medicine is held in high esteem around the world. The efforts of Irish medical schools and our Royal Colleges encompass not only postgraduate education, but also undergraduate teaching.
Conversely, young Irish doctors in all disciplines sought further training in prestigious hospitals and medical schools around the world and most returned to make their knowledge and skills available to the service of Irish patients.
The system worked, not perfectly, but pretty well. With medical advances, financial strain became evident. Rising medical inflation, more expensive “must-have” equipment, newer drugs and treatments drove costs inexorably upwards.
There were also the effects of wage and fee inflation, exacerbated by the fantasy world of benchmarking. Problems clearly lay ahead and there was little evidence of prudent planning or anticipation. “A stitch in time” was an alien concept to the powerful political and administrative minds of government and the HSE.
Throughout this time and despite ominous portents, the training of young doctors was not neglected, although increasing subspecialisation created further demands for appropriate education and additional staff.
The European Working Time Directive (EWTD) placed restrictions on the number of hours the doctors in training could work. I wrote several years ago that this was going to lead to major difficulties in teaching and in service delivery. So it has proved.
The HSE tells us that the number of such NCHD posts has increased from 2,582 in 1996 to 4,642 in 2008. This is consequent upon the changes listed above and should not surprise anybody.
If we have a more complex health service we need more people to run it. The doctors still needed to be taught and such necessity led to concessions being made to those delivering the service.
The conditions and terms of service of the NCHDs were ameliorated. Training grants and allowances for doctors with higher qualifications were introduced and welcomed. A living out allowance was conceded for those on call and who could not, for space reasons, actually live-in. Attempts were made, in so far as was possible, to curb some of the more excessive hours worked.
However, clouds were gathering. These were the days of the faux boom when the HSE was created, supplanting the health board structures that had managed hitherto. The old boards had been held to be inefficient and overmanned.
The new broom was going to change everything. It did. Everything got worse. There was no increase in efficiency and no economies of scale. There were labyrinths, ill-understood by all except the internal hierarchy and designed to delay and frustrate decision making within the system.
No money was saved and nobody seemed to care. The result was layers of grandiosely titled administrators and the stagnation of front-line services.
Scandals like PPARs scarcely raised a ripple, after all it was only money and there was plenty of that. There wasn’t even any need to work too hard. If there was a problem you could simply commission a report and when it was delivered you could let the Minister spin it for a few days and then quietly forget it. You didn’t even have to read it.
The aforementioned clouds turned blacker, the money ran out. The HSE talked about cost containment, cuts to you and me. Where did they look first?
Lip service to medical education was forgotten. The NCHD training grants were abolished forthwith, as was the allowance for higher degrees. The living out allowance was to go.
There were changes in overtime and best of all; wait for it, “an unpaid meal break of one hour can be introduced for all NCHDs”. This would bring doctors into line with other grades in the health service!
Maybe things have changed, but I think not. Never in my time and I am assured since, have NCHDs enjoyed the luxury of such guaranteed meal breaks. If we are to save money in the health service, whoever dreamed up this mean penny-pinching exercise, should be the first to go. It just goes to show how little these people know about how hospitals work.
“Sorry about your husband missus; he died during my lunch break.”
Maurice Neligan is a cardiac surgeon