A matter of life and death

  • Niall Hunter, Editor


Try though he might, Health Minister James Reilly doesn't often get things right and tends to promise more than he delivers.

Sometimes, however, he does display a knack of getting to essence of a major problem in our health service and what should be done about it, and for this we should give him some credit.

The reaction from a consultant organisation in opposing the Minister's modest proposal this week that clinical outcomes of individual consultants, including their patient mortality rates, should be made public, tells us a lot about what is wrong with our health service at the moment.

It reminds you of the saying: 'everybody wants to embraces change, until it actually starts to happen'.

From the evidence to date, the medical profession is not too crazy about the clinical performance of its members and the institutions they work in being made available for the public to examine and compare.

Addressing the MacGill Summer School in Co Donegal, the Minister has asked a question so glaringly obvious it's a wonder people don't ask it more often, or why they aren't marching through the streets about it:

"Wouldn't you like to know how safe your hospital is?"

Most people would answer yes to this. It's something many might not have thought about before, even after some recent health safety scandals.

Those who have thought about it and attempted to find out how safe a hospital is compared to another, and how competent the people are who work in it, are bound to be frustrated.

A quick Googling and trawl through hospital and HSE websites will show you that there's practically zero health service-provided, properly audited information out there that tells you the level of quality and safety in hospital care.

We are frequently assured that overall, we have a good standard of healthcare in Ireland. We probably do (it would be an 'appalling vista if we didn't), but to date we have no concrete data to prove this - we have to rely on assurances from those on high (usually after the latest safety scandal) that this is the case.

Asking the public to have confidence in the quality provision of healthcare without giving them concrete data on which to base to base this confidence is an insult to people's intelligence.

Dr Reilly is, of course, perfectly reasonable in suggesting that those who pay for the health service are entitled to know 'what the morbidity and mortality rate of the guy operating on you is'.

To judge from a statement from the Irish Hospital Consultants Association (IHCA) in response to this, the Minister's brutal logic is perhaps a little too real for some doctors.

The IHCA is, of course perfectly entitled to represent and look after the interests of its members, and I'm certain its intention wasn't to dodge the issue.

Yet its statement seems to be a perfect example of an interest group opposing something it feels threatened by, but in attempting not to sound too unreasonable, merely confuses the public.

Hence:"The IHCA is in favour of patients receiving all information relevant to making an informed decision about their care programmes."

This statement sounds worthy, but when analysed, it has very little meaning; like the Pope saying he doesn't thinks sin is a great idea. Also, it doesn't explain what is 'relevant' and 'irrelevant' information, and who would decide on the relevance or otherwise of the information to be revealed.

Now comes the clincher: "The Minister's plan to publish morbidity and mortality rates for individual consultants will not in its present proposed form help patients to make informed decisions."

Two points here. What do they mean by 'in its present form?' The Minister, as far as can be ascertained, has not published detailed proposals on the ins and outs of  how the 'consultant league table' might operate. Consultants appear to be condemning the plan as soon as it has been announced, while knowing little about it.

The Minister has merely announced the 'endpoint' - that morbidity and mortality rates of individual consultants will be published.

So the only 'present form' that exists is that the Minister intends to publish clinical outcome data on individual doctors. That presumably is going to be the outcome, whatever the mechanics of the process.

One cannot escape the impression that the organised profession is opposed to the concept of publishing clinical data on consultants, full stop, in any workable shape or form.

The second point here is, exactly what data or published information do patients have at the moment to help them make informed decisions about their care by particular professionals in particular institutions? None whatsoever.

Patients certainly have very little concrete information available at present on which they can decide which hospital or consultant to choose.

The IHCA points out too that nowadays, healthcare is increasingly delivered by teams of doctors and other professionals in hospitals. This is certainly true and is very welcome.

The Association further argues however, that in this context, linking morbidity and mortality to one particular factor or individual involved in a patient's care 'may not be the most appropriate way to reassure patients of the safety of their hospital or a hospital group'.

To which a cynic might respond, 'maybe so, but it would certainly help'.

And, FYI, here's a statement that appears on the IHCA's own website:

"When you are admitted to hospital, either in an emergency or on a planned or elective basis, you will be under the care of your admitting consultant. Your consultant leads a team of doctors, with whom you will have most contact. And: "Should your illness warrant it, the consultant will personally deliver the appropriate care."

Any logical reading of this statement would infer that the individual consultant trusted with the care of a patient  is usually at the head of the treatment pyramid, and therefore, is responsible for that care and for the results and the outcome of that care.

How does this tally with the IHCA's statement this week, which implies that a consultant is, in fact, merely a cog in the team wheel and that no one person can ultimately be held responsible for patient outcomes?

One would think that anyone planning or running a health service, or indeed a member of the legal profession prosecuting a negligence case, would insist that one highly paid and well trained consultant takes charge of the treatment team when it comes to ultimate responsibility for the care of the patient and the outcome of that care.

Any patient too, would like to think that somewhere along the line, someone is going to take charge and accept responsibility for their care. Otherwise, it just leads to buck-passing when things go wrong.

Certainly, some doctors and hospitals, not to mention health service managers, have a long way to go before they 'get' the concept of accountability and transparency.

A salient point here is that Minister Reilly's proposal takes things much, much further than the level of accountability we have at present. We do not even have a system that compares clinical outcome rates among hospitals, let alone among individual consultants.

There is considerable resistance to individual performance comparisons among many medics.

Recently, a planned audit of mortality following surgical procedures was delayed due to consultants' concerns over confidentiality and data protection issues.

This audit would involve surgeons reviewing the outcomes of procedures undertaken by their colleagues, with the reasonable intention of identifying gaps in performance and improvements needed.

However, unlike with Dr Reilly's proposed system, there were no plans to publish individual doctor or hospital department outcomes under this audit.

Yet there were concerns that individual surgeons and their performance could be identified publicly under the system through Freedom of Information or document discovery in legal cases, or that surgeons reviewing their colleagues' work could be identified.

To be fair to the IHCA and individual doctors, they may have fears that if the published information on individual doctor and hospital performance is not collated properly, it could lead to inaccurate information or unfair comparisons and therefore, victimisation or 'witch-hunts'.

However, any competent medical practitioner or hospital department should have nothing to fear under any properly-run 'league table' plan.

Minister Reilly's has given no indication that his scheme will not take into account issues such as volume of patients, the age of patients, whether they had pre-existing conditions, how critically ill they were on admission, level of complexity of surgery etc, to ensure that like is compared with like in these 'league tables.'

No reasonably sentient Minister would plan such a flawed audit, as it would have no credibility.

Irish doctors are on the whole, better trained and better regulated than they have ever been. As a result of hospital reorganisation, more complex care is moving from smaller to larger hospitals, thereby improving clinical skills and generally reducing patient risk.

When they are published, Minister Reilly's clinical outcomes tables are in the majority of cases, unlikely to show major differences between the performances of individual doctors or hospitals.

The real benefit of such exercises, in addition to the public getting real information on service quality, is to identify the small number of 'outliers' in terms of individuals, departments or hospitals that might not be performing up to standard, so that corrective action can be taken.

In this way, we can keep major adverse incidents and ensuing safety scandals to a minimum.

When deciding how much should be revealed in these audits, doctors argue, the public interest has to be balanced against the need to have 'buy in' by the medical profession into the process.

Minister Reilly has indicated that, in matters of life and death, the public interest should always be paramount.

And yes, we should also have published league tables of Ministers and TDs!







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