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.)

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