Fintan O’Toole: In health system culture change is just a buzzword

Ireland has failed to create a health service owned by people and not vested interests

Taoiseach Leo Varadkar: Along with many others, he has lacked the will, the skill, the ruthlessness and the vision to create a national health system that starts with the patient. Photograph: Niall Carson/PA

Taoiseach Leo Varadkar: Along with many others, he has lacked the will, the skill, the ruthlessness and the vision to create a national health system that starts with the patient. Photograph: Niall Carson/PA

 

“Culture change” is a phrase politicians like – a quick search suggests that it has been used 144 times in the Oireachtas in recent years. The Taoiseach, Leo Varadkar, used it again last week in his most considered response to the cervical cancer screening scandal.

He acknowledged that it had been a “dreadful week” for the health service and suggested that a “culture change” was needed to address “a failure of open disclosure by doctors and also a failure by senior management to make sure that that happened”.

Fair enough: who could deny that the culture of the health system needs to be transformed? But there are three good reasons to be sceptical when these buzzwords are used to address such fundamental failures.

First, we’ve heard it all before. To take just one example, Mary Harney, who was then minister for health, told the Dáil in 2006 that the report into the Michael Neary scandal at Our Lady of Lourdes Hospital in Drogheda “must mean a sea-change in culture . . . a systematic, continuous and open approach to error reporting and correction involving everyone in the healthcare setting . . . The culture will change.” Culture change seems remarkably bad at changing the culture.

Second, there is a history of using “culture change” as a way of not talking about individual accountability. If the culture is where the fault lies, no one is to blame – the culture made them do it.

Here is Leo Varadkar himself as minister for health in 2014, addressing a conference on patient safety: “We now recognise that ‘blame cultures’ only lead to further problems, as people are afraid of identifying the real causes of failure. Instead, we are working to create a ‘safety culture’, encouraging open reporting and balanced analysis, and embedding this culture in practice . . . Failures sometimes occur, through a combination of active failure and latent conditions, and it can be a mistake to focus only on the individuals involved and not the wider factors.” 

Personal impunity

The problem with this is not that it is wrong. It is, indeed, vital that people working in the health service are encouraged to report mistakes they have made, knowing that if they do so in a timely and honest way, they will not suffer for it. But with Ireland’s long and deep history of personal impunity for bad practice, the avoidance of a “blame culture” very easily slips over the borderline into the evasion of personal responsibility.

The essence of professionalism is accountability – without it, as we see time and again, nothing changes for the better. While Varadkar was right to say that we should not focus only on individuals, that tends to translate in practice into not focusing on individuals at all. It is all “wider factors” and no close-ups.

Third and most importantly, the real culture change that has to happen is political. The core problem with the Irish health service is that it has never really been established. There has never, in a State that is almost a century old, been a government that decided once and for all to create a national health service that truly belongs, not to consultants or institutions or professional interest groups, but to citizens. In the 1940s and early 1950s, while post-war European countries were developing national health systems, Ireland failed to do so. 

The long-term result is not just a system that is incoherent, inefficient and unjust

This was not primarily because of the State. The Department of Health produced radical proposals for a national health service in 1945. The Catholic church, allied with right-wing doctors, opposed it on the grounds that it infringed the rights of the family.

An unholy alliance was formed. The church did not want to lose the prestige it got from providing health services and its control over the “moral” dimensions of medicine. The consultants did not want to lose the lucrative extra income they got from being able to combine public contracts with private practice – a privilege unique in the developed world.

Patient vs system

And this alliance won the battles. The long-term result is not just a system that is incoherent, inefficient and unjust, though we certainly have that. (We spend as much on healthcare as countries that have genuine national health systems.) It is a system owned by interest groups rather than by the people.

So long as this remains the case, there will be no “culture change”. So long as medical professionals are allowed – indeed encouraged – to think of what they do as in a very real sense private, there will never be a profound conviction that the system serves the patient rather than the other way around.

For all the excellent and decent people who work within it, the culture will always be capable of thinking that maintaining its own prestige is more important than dealing with and correcting mistakes.

This culture won’t change itself – in fairness, it probably can’t. Cultures change, not because they want to, but because they have to. Leo Varadkar as minister for health didn’t do much to create these fundamental imperatives and neither did most of his predecessors or successors.

None of them has had the will, the skill, the ruthlessness and the vision to create a national health system that starts with the patient and works back from there.

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