How can we fix our healthcare system?

By Dr Bernadette Carr*

“X-Rays will prove to be a Hoax."
“Radio has no future.”

 A former CEO of Coca Cola once said: “if you think you can run an organisation in the next 10 years as you have run it in the past 10 years then you are out of your mind.”

How will Irish healthcare be delivered by the year 2020? How will it differ from what we have today? Will it be better or worse? And most importantly, what would we like it to be?

If you were to believe everything we hear and read in the media, nothing is right and everything is wrong.

However, we all know that good news stories don’t necessarily make news. However, the old Irish saying of “well I wouldn’t start from here” probably applies and the way to simplify it would be to take the current system, identify all the problems and start again.

While this might appear to be an easy solution, I think it would do an enormous disservice to those who provide the care in the Irish healthcare system and most importantly to the patients who receive that care. 

Although it is probably fair to say that at no time in the history of medicine has the growth of knowledge and technology been so profound, I also believe that it’s quite possible that the level of mistrust which has been generated towards the healthcare system has never been higher.

Although genomics and other new technologies on the horizon offer the promise of further increasing longevity, improving health and functioning, eliminating pain and suffering and advances in rehabilitation, cell restoration, and prosthetic devices hold the potential for improving the health and functioning of many with disabilities, paradoxically, as medical science and technology has advanced, the healthcare delivery system has floundered in its ability to provide consistently high quality care to all patients.

Research on the quality of care reveals a healthcare system that frequently falls short in its ability to translate knowledge into practice and to facilitate clinicians in their desire, to apply new technologies safely and appropriately.

Performance of the healthcare system varies considerably.  At times it is exemplary but sometimes it is not, and some patients fail to receive effective care.

If the healthcare system cannot consistently deliver today’s science and technology we may conclude that we are even less prepared to respond to the extraordinary scientific advances that will surely emerge during the next twelve to fifteen years.

I believe that Irish people can have a healthcare system of the quality which they need, want and deserve but I also believe that this higher level quality cannot be achieved by further challenging the current systems of care.

The current healthcare structures cannot do the job, trying harder will not work; changing systems of care will. Safety flaws are unacceptably common but the effective remedy is not to browbeat the healthcare workforce by asking them to try harder to give safe care.

Members of the healthcare workforce are already trying hard to do their jobs well. In fact the courage, hard work and commitment of doctors, nurses and others in healthcare today are the only real means we have of stemming the flood of errors that are latent in our healthcare systems.

Healthcare today has safety and quality problems because it relies on outmoded systems of work. Poor designs set the work force up to fail regardless of how hard they try. If we want safer, high quality care we will need to have re-designed systems of care including the use of information technology to support clinical and administrative processes.

So, if we believe that improved performance will depend on new system designs, how do we design such a system? Well I don’t believe it is possible to specify in detail the design of a twenty first century healthcare system which is replicated identically throughout the delivery system. Imagination and valuable pluralism exist in this country in the nation’s healthcare enterprise and I believe this should be encouraged further.

Leaders of healthcare institutions are under extraordinary pressure, trying on one hand to strategically reposition the organisations for the future and on the other to respond to today’s challenges such as budgetary constraints, altered regulatory structures, rising expectations and rising demand.

For several decades, the needs of the industrialised society have been shifting from predominantly acute episodic care to the care of chronic conditions.

Chronic conditions are now the leading cause of illness, disability and death. They affect a significant proportion of the Irish population and account for the majority of healthcare expenditures, particularly in the public system where we see significant increases in expenditure on pharmaceuticals (the demand led schemes described by our colleagues in the public system).

There remains a dearth of clinical programmes with the infrastructure required to provide the full compliment of services needed by patients with heart disease, diabetes, asthma and other chronic conditions.

The fact that more than 40% of people with chronic conditions have more than one such condition argues strongly for more sophisticated mechanisms to communicate and coordinate care. In these conditions, hospitals and other healthcare organisations often have to provide care without the benefit of complete information about the patient’s condition, medical history, services provided in other settings or medications prescribed by other clinicians.

The challenges of applying information technology to healthcare should not be underestimated. Healthcare is undoubtedly one of the most complex sectors of the economy. The number of different types of transactions i.e. patient needs, interactions and services is very large.

Sizeable capital investments and multi-year budgetary commitments to building systems will be required, and widespread adoption of many information technology applications will require behavioural adaptation on the part of a large numbers of patients, clinicians and organisations.

Yet the internet is rapidly transforming many aspects of society and many health related processes stand to be reshaped as well. Long term national commitment to this will be required if significant progress is to be achieved in this area

In addition, more resources must be devoted to chronic illness and to prevention. It is clear that much change has been embarked upon in this country which should lead to improvement. However we are just at the beginning of this change process and the outcomes are not yet in sight.

None the less, medicine is an old discipline and what will survive as the world changes are its underlying  principles:
* Clear, ethical values
* Putting patients first
* Constantly trying to improve
* Basing what we do on evidence
* Leadership
* Learning.

In my view there is no doubt that health will increasingly be at the centre of the political process. I also believe there is a chasm between what healthcare could do and what it currently does but that some things like ethics, learning and leadership will continue to be important whatever happens. 

The future is highly unpredictable; the point is not to try and predict the future but to prepare for it and help shape it.

In conclusion to paraphrase Shakespeare, the healthcare system itself is ill, but being wise, it will recognise this and embrace the means to achieve a full recovery.

*Dr Bernadette Carr is Medical Director of VHI Healthcare

(The above article is based on a recent presentation to the annual meeting of the Irish Hospital Consultants Association.)


brandy - 07/10/2008 20:51

How can we fix our healthcare system? 1. Dispense with people/systems that are definitively not efficacious regarding health provision... i.e: bureaucrats/paper-pushers who 'pour down the plug-hole' much of the money that would otherwise be spent on the front-line....they are an unnecessary drain on resources! 2. Re-introduce the cleaning system whereby the HSE has a permanent cleaning staff....responsible to each hospital and the health-authority. 3. Insure that all doctors (all)), including radiologists, nurses etc...are properly/securely vetted. If a fault is discovered in the vetting...immediate dispensing/sacking of the person pension no compensation! 3. If the above are not implemented (as a beginning)....all the HSE executive and the minister responsible....will have their pensions (and all bank/shares accounts infused into the tax-payers pension fund) so that those that voted for the politicians will have some form of recompense for the abuse they've been subjugated to over the years!!

Peter 47 - 09/10/2008 16:23

Well said brandy !! There is not enough space in this note to start to list the changes needed, not now, but over the past long number of years.. We have a situation where the waiting lists are put on stand by, for a couple of months, in the mean time there is a 2 or 3 day week,,,, what will the surgeons do on thier days off ??? Will they be paid , or will they catch up with the (small) backlog of "Peivate" operations, while medical card holders are left on the long finger, to struggle on enduring pain and suffering, and consuming heaps of "Medication" which is perhaps more expensive than the surgery cost if counted back over the wasted years on the waiting list How to fix it !! Well for a start, all communication between your GP and your Hospital should be by e-mail... 55 cent saved each way,,, Replies should be next day, patients in pain should not have to wait. There are far too few Consultants in all fields, some of those already on the "list" are doing too much "Private" work, and others are way behind the times. No patient should have to wait weeks... just to know when thier apointment will be, and where , and with whom. Idealy they should know the next day, and in a perfect world, only days between the request, the consultation, and the necessary procedure taking place. this is what happens in private health care.. GMS patients procedures are paid for and cost the same as "private", or so we are told,,,, so what is the reason for cut backs, short time, delays and for some... DEATH... while waiting for the service they have paid for in advance all thier working life More next time... I need to take a break for me MEDS. Peter 47

Absyrd - 09/10/2008 20:18

This rambling litany of dos and donts is typical of what brought us to this unholy mess. Ideologically we are in a confused state! Lost between public universal health care and creeping privatisation. No effective model of Public Management with poor attempts at managerialism in traditional virtual monopolies and opportunistic privateers. Where we are going to depends on what we have become; what our priorities are now and for the future!

wwwsoldiersofdestiny - 09/10/2008 21:41

If dead people are not getting letters of confirmation of hospital specialist appointment( to check if they are still alive and maybe move somebody else up the list))-in2020, thatīs what I will call progress (if I am still alive then..)

AB - 10/10/2008 08:51

Wel we did try and scrap the old system and start from the beginning when we scrapped the Health boards and instituted the HSE - and look at the mess we have now. Brandy, I agree wholeheartedly with 1, 2 and 3 as they are eminently suitable suggestions. The part about all the HSE executive and the minister responsible will their pensions and all bank/shares accounts infused into the tax-payers pension fund is very funny but as we all know it entirely untenable and most probably unconstitutional - tempting and all as it might be. Peter, I agree also, patients in pain - be they medical card, public, private or anything else should not have to wait. Some consultant are indeed antiquated and there are far to few in most or maybe all fields but you can see the battle that as waged - in order to get new consultants, existing consultants had to agree to have them on baord (a bit like my manager having to ask me about new staff she intends to take on!!) and then the new consultants had to be negotiated with in relation to their contract - which they would not agree to without having provision for a certain number of hours or amount, of private work.

daisy - 10/10/2008 09:48

Its true I have spina bifida and scolosies I am now in my late 40s the care I reiceved in 70s was much better, today they cannot relieve the pain I am in every day, told to live with it I do not think that is progress what do I pay tax for. Doctors are too concerned with litigation. There is no proper referral system, I am fed up getting letters from HSE for Database, when is has been of absolutely no benefit, even with Spina Bifida and scolosies I cannot retain my medical card. This a bad situation as I cant afford to take medical private insurance as the loading is too great.

Peter 47 - 10/10/2008 17:12

Daisy I have evry sympathy for your condition. I am not familiar with your situation, but it seems you do not qualify for a GMS Card on the grounds of your household income... Get a new form.Fill it all in and add a page or two of details, regarding extra expenditure due to your condition, not included in the application. There is a HSE allowance for fuel, you need extra heat, put in a heap of euros for heating. There is a HSE scheme for Transport costs,,,Mobility allowance, add in an amount for transportation needed for your condition Do you need any special diet ? add in how much you spend extra for your condition Be sure your allowed for your housing needs, If you are a differential rents client, have it reviewed,,, if you are paying a mortgage, allow for changing mortgage price (rises) Go along to your local Citizens Information Centre They will take you up to speed, if there is anything else you can add in as above normal expenditure in your house hold Finally, if you are refused, ask for a detailed list of the amount you are over budget, to let you qualify for the GMS card. Take all the time you need and make every effort to show your position, for the claim You can contest the refusal if it comes any where the limits.

Myrtle - 13/10/2008 22:49

I work in the HSE. See millions spent on various computer systems; some of which were only implemented and then dropped because of improper training, etc... A total waste of resources!

AB - 14/10/2008 16:16

True Brandy but a constitutional change requires a referendum - can you see that shower of incompetent wasters bringing forward a referendum on anythign that doesn't suit them??

AB - 17/10/2008 08:41

'me-me land' - oh that's a good one Brandy As it happens, the changes I find most offensive in the budget are the removal of medical cards from the over 70's and the 1% affecting those on minimum wage and these things don't affect me at all. I like your suggestions re: churches taking in the homeless at Christmas - perhaps the celtic tiger hypocrisy has effected the management/hierarchy at the church more than they would care to admit! I would disagree as regards the "cushy-celtic-tiger pads" - even where these are built to the best standards (and not many seems to be) those in them are most likely paying thru the nose for mortgage for far more than the property is worth and undergoing a massive struggle to do so.

AB - 20/10/2008 09:57

Oh absolutely Brandy, they should indeed be incensed. Ah no Brandsy, you won't find any politician, or politicians' daughter or son in that situation. Their posteriors are well covered.

AB - 21/10/2008 10:59

Brandy, I find that there are some people who just do not want to be enlightened or informed becuase it suits their own ends not to be - none so blind as they who do not want to see, sort of thing. A bit like Obama comment about putting lipstick on a pig - You can show people the mess, the crisis and the problem but you cannot make them recognise it as such.

Anonymous - 29/10/2008 00:55

simply mended,a swift boot to brendan drummer boy,out with the hirachy,general election and DONT vote these muppets back in,

Peter 47 - 29/10/2008 15:08

Tis beginning to look like the present shower are due for a rest on the opposition benches They are sending out all the right messages to allow a "no confidence" vote... First time you see a shortage of supporters on the Government benches (due to sickness of course) you will know they have decided to leave the country in the state they left it last time. Watch out for the Ghost of the Celtic Tiger, it might not be today, or tomorrow, but please make it soon.......... Peter 47

Peter 47 - 29/10/2008 15:52

Well isint that great... We're losing over 3 million per day, "The celtic worm" (c) is crawling through Leinster House Now we know that it takes about a million euro to actually put on a general election (plus of course all the allowable, returnable expenses) Do the majority think (or know in their hearts) that it would be money well spent ?? Should we wait for the "backhanders to Fianna fail " Tribunal to finish?? Are the spin doctors and Advisers to the government really costing as much as the "wages" the clowns themselves get ?? Can we aford NOT to have a general election as soon as possible, ?? Can the present "Health Service" realy believe that closing wards is a way of saving money, while the Doctors, nurses, cleaners, and clerical staff, all have to be paid ??

AB - 04/11/2008 11:23

Brandy, on point 1. I agree entirely or instead of sacking them, get them to do the paparwoek nurses seem to be doing more and more of so that nurses can do more nursing again. However on point 2. If the Gardai and the other emergency services rotate through 24 hours and have a 7 day rota...why don't 'critical' paper-pushers have to do the same? - Becuase their terms of employment probably state 9 to 5. In order for new terms to be instated, new contracts would have to be negotiated and so a shift premium for this would, IF and it is big IF, the unions would allow it, would probably be ruinously expensive. On point 3, this I beleive was what Mary Harney is apparently trying to negotiate with the new consultants contracts. That ministers accept portfolios and then have to employ advisors to thier job is ludcrous. I can't see any politician taking up your challenge tho Brandy, they don't have the "b*lls", in my opinion

AB - 05/11/2008 16:33

Brandy, the fact of the matter is that now, people whether they work in hospitals or shovel coal, if they do shift-work rotated through 24/7, then they are entitled by law to a shift allowance / premium. This is a legal entitlement which applies to all and serves to protect the lower paid also as well as all workers rights. This is why the 24 hr clock not utillised (mandatorily). Indeed many were glad to have continuous/regular work throughout the 70s/80s, as I remember to and many did overtime unpaid and still do so. Many left because there was no work - menial or otherwise, which is why unemployment stood at 17 and 18%. Of couse any honest work is to be lauded, I agree. The Lords n Ladies in Leinster House to go 24 X 7 in their duties - Oh they would tell you they aleady do. Seriously, I recall listening to one of them not so long ago. Pure comedy if he hadn't been serious.

Anonymous - 05/11/2008 22:21

Strap the lot of the hierarchy to the beds and give them a fine large bore needle with a long acting sleep dose. We could throw the Health Minister in too. Then we might get some rest from listening to their yarn-spinning.

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