Patient harm scandals led to reform plan

  • Niall Hunter, Editor

The hospital revamp plans published yesterday by Health Minister James Reilly came with as distinct aura of deja vu. We have been here before.

The announcement of the Minister's plans marked the culmination of a troubled process that started back in 1968, with the publication of the Fitzgerald Report, which called for hospital services to be reorganised and for smaller hospitals to no longer provide major surgical and emergency care.

In fact, plans to reform how our hospitals are organised can actually be dated back to the 1930s, not long after the foundation of the State.

A depressing backdrop to the fanfare over the hospital revamp announcement is that is it really only being put in place because patients have been unnecessarily harmed, or in some cases have died, due to our inefficient and sometimes unsafe hospital system.

Ireland has traditionally had a higher proportion of hospitals per population compared to other countries.

The comely maidens dancing at De Valera's crossroads in the 1940s would not have had too far to travel had they indulged in some excessive buck-lepping and broken their ankles - there was an all-singing, all-dancing, open all hours hospital at practically every crossroads anyway.

Attempts to reform the system in order to make it safer, more streamlined, and more cost-effective have traditionally foundered on the rocks of local vested interests and political opposition.

Change is now taking place not really as a result of altruism or high ideals, but through pragmatism and necessity.

As the new report on smaller hospitals states, much of the the debate about the role of these hospitals has been prompted by the need to deliver safe services.

Due to their size, smaller hospitals can only treat relatively small numbers of patients with more serious conditions.

This means that clinical staff do not treat certain conditions often enough to ensure that they can maintain their skill levels.

This basic equation seems to have been lost on or ignored by vested interest groups over the years.

The greater the patient throughput, the more that skill levels can be built up. The bigger the hospital, the better the range or specialised facilities that can be used to treat the more serious cases safely. And rearranging hospitals into groups will help boost this 'critical mass' by the sharing of staffing and infrastructure.

While they are losing some services, smaller local hospitals can provide a wide range of extra local services, making it more convenient for people to access care close to their homes, and leaving the larger hospitals to get on with more complex planned and emergency work.

The report also, however, makes the salient point that larger hospitals are not by definition safer than smaller ones. Usually, larger hospitals can provide safer care, but just because it's a big hospital doesn't mean it's as safe as it can possibly be.

We recently witnessed some major patient safety controversies at larger hospitals - Tallaght in Dublin, and of course, with the Savita Halappanavar case in Galway. The report stresses that vigilance is needed to ensure that hospitals of all sizes meet safety standards.

This will be helped by the planned hospital licensing process, whenever that finally arrives. It might also help too if, like the UK NHS, we published comparative mortality statistics among hospitals, which would bring more transparency and accountability to maintaining safety standards.

While Minister Reilly must be given some kudos for finally producing a hospital revamp plan that may actually be implemented (and has begun to be implemented in some regions already) let's not get too dewy-eyed that about this brand new dawn.

In recent years, hospital service reorganisation has been forced on Governments and health managers by the exigencies of major safety issues that caused patients to be harmed, or in some cases, lose their lives as a result of poor care provision.

Added to this, diminishing financial resources led to a questioning of why we needed so many major hospital centres so close together.

Unfortunately, there are some patients who would be alive or unharmed today if we had implemented a more streamlined and safer hospital system many years ago.

A blueprint to concentrate breast cancer services into a smaller number of major centres lay on the shelf for eight years before scandals over wrong diagnoses forced the hand of the health authorities.

The report was drawn up in 2000 but its implementation did not start until around 2008, after a number of misdiagnosis scandals.

The author of that report, Prof Niall O'Higgins, told in 2007 that some women in Ireland who had died from breast cancer would still be alive if the Government had implemented the reorganisation of cancer care into a small number of specialist centres more rapidly.

Concerns expressed by the safety body HIQA about the continuation of major ED, acute surgery and other services at smaller hospitals, following a number of safety complaints, finally led to the nettle being grasped on changing the delivery of local hospital services.

In the coming weeks and months we will witness much debate about James Reilly's hospital plan.

Ultimately, any arguments about the status of various hospitals and the logistics of hospital groupings under the new plan are largely irrelevant and to a certain extent self-serving.

The ultimate aim is to provide a safer and better quality service for patients.

The reorganisation plan, therefore, should be welcomed by anyone who wants a better hospital service.

However, before we get carried away with praising the Minister for his vision, there are few nagging worries.

You can rearrange hospitals into as many groups as you want - if they are not resourced properly and proper in-house safety systems are not put in place, you will never get a better quality health service.

It should be noted that Dr Reilly's hospital announcement comes at a time when more than 100,000 people are waiting over a year for an outpatient appointment and treatment waiting list numbers have started to rise again.

What's more, access to our hospital system is as inequitable as ever. A recent study by the Irish College of GPs shows that public patients often have to wait months for CT scans and other tests, whereas private patients can get these carried out in a matter of days.

The health service budget has been reduced by just over one-fifth over the past five years. Many would question whether this level of funding cut can guarantee a safer service, whatever new efficiencies have been put in place. And there are to be further funding cuts next year.

The other worry is that the hospital reorganisation ties in with Dr Reilly's plans for 'money follows the patient' and, eventually, universal health insurance (UHI).

Many would worry that a system that rewards hospitals for the level of work they do, if not properly regulated, could just lead to them carrying out unnecessary treatments and tests to boost their income.

And there are still big questions over the affordability of UHI. Asking health insurance companies to run your health system is throwing caution to the wind a bit in terms of future cost control.

And finally, the new hospital groups will eventually progress to becoming independent, self-governing hospital trusts.

Again, proper regulation and oversight is required here. Many of the recent healthcare scandals came about as a result of individual hospitals being left too much to their own devices.

We have seen from the UK experience that the setting up of independent hospital trusts is not exartly plain sailing. In fact, it led to the scandal of Mid-Staffordshire, where hundreds of patients died due to substandard care.

Unfortunately, under the universal healthcare plan, with the HSE being abolished, it is as yet unclear who will be providing oversight for the system after 2016.

However, Dr Reilly's hospital plan must be welcomed as a long-overdue step in the right direction.

Major shake-up of hospital system










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