Lack of accountability a huge barrier to better healthcare

Fixing the Irish health service is an enormous but not impossible task. The public, or more accurately the 60 per cent of the population who do not have private insurance, can take little comfort from the multiple failed attempts by successive governments to address what amounts to a denial of their right to access timely healthcare.

The most recent data shows that 556,000 patients are waiting for an appointment or treatment, with 96,000 waiting for an outpatient appointment for more than 12 months. In addition, the number of patients awaiting admission while languishing on trolleys, sometimes for days, remains at around 500.

What is even more distressing is the fact the frail and the elderly are disproportionately represented among those waiting for care.

The future is even more alarming. We are faced with both population growth and an aging population that will require more care, a well as dramatic increases in obesity, diabetes and alcohol-related illness. All together they signal a crisis that can only get worse unless meaningful, effective and sustained action is taken now.

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What patients want

Putting the patient at the centre of how services are designed, organised and delivered is what the Irish public want and deserve. This is the resounding message from the patients and carers, health professionals, policy specialists and hospital managers who came together in the Royal College of Physicians of Ireland Towards 2026 policy forum to develop a vision for the health service for the next decade.

Putting patients at the centre means genuinely listening to them during the planning, design and implementation of the services they require. They are the users of these services, and their experiences and expectations will inform and support the necessary transformation.

It was recognised that keeping people well and facilitating healthy lifestyles will play an increasingly important role in preventing illness. Increased investment in education on the benefits of lifestyle change can be hugely cost-effective. Legislation such as the proposed evidence-based Public Health (Alcohol) Bill, as well as increasing taxes on tobacco, are important legislative tools to reduce the future burden of illness.

A recurrent issue during our discussions was the lack of accountability at all levels of the health system. While not unique to healthcare in Ireland, it is a repeatedly demonstrated fundamental weakness, which undermines confidence in the system and is a huge barrier to improving care.

To address this deficiency, there needs to be a cultural shift away from the current blame culture. This will require putting in place a robust and transparent corporate and clinical governance system, one in which patients play a significant role.

Building on

Some of the recommendations in the Towards 2026 report build and repeat recommendations seen in previous reports in Ireland and other comparable countries. These include recommendations for investment and implementation of a system-wide, interoperable electronic health record to facilitate joined-up care.

It is acknowledged that the HSE is proceeding in this direction. Still, given its importance and value, the limited investment needs to be increased and the timeline for implementation shortened.

The report also supports the present policy of expanding and enhancing primary care and the expansion of diagnostic facilities outside hospitals.

The vision for hospitals expressed in the report is less about “fixing” existing hospitals than imagining a future “hospital without walls”, where many services take place in a community setting.

The report also highlights the crisis that now exists in the recruitment and retention of doctors, nurses and other healthcare professionals. The continuing atmosphere of crisis not only compromises patient care, but is taking an unsustainable toll on healthcare staff.

Serious and focused effort is required to strengthen and support staff at every level and to rebuild their trust and confidence. This must include improved workforce planning and career and skills development, but also developing changed and expanded roles and responsibilities to meet patients’ needs.

There will have to be an open, honest and informed debate about what can reasonably be expected from the health service. This debate must be prepared to admit that the system requires total redesign rather than band-aid fixes that treat the symptoms rather than the underlying illness.

Inherent goodwill

In my conversations with patients, carers and health professional over the past year, I have been impressed by their inherent goodwill and lack of recrimination at the failings of the system. But I have also sensed that the tipping point of total system failure cannot be far off.

Major change must occur before that point is reached in order to prevent consequences that will have a profoundly negative impact on the health and wellbeing of those dependant on publicly funded healthcare.

My own experience in working to implement a radical redesign of cancer services in Ireland a decade ago is instructive. Cancer outcomes and quality have improved significantly. The reasons are many, but those most prominent are a well-designed evidence-based plan, strong clinical leadership, excellent communication and, perhaps most important of all, strong and sustained political support.

As the Oireachtas Future of Healthcare Committee finalises its 10-year plan for the health service, I hope the recommendations in our report inform their work. With a clear vision and cross-party support, I hope a realistic and radical plan for change can be implemented.

Change will require political risk and sustained support, but action now cannot be avoided or deferred.

Tom Keane is chair of Towards 2026, a policy initiative from the Royal College of Physicians of Ireland. Dr Keane, an oncologist based in Canada, is the former national director of the Cancer Control Programme in Ireland.