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Finding the balance in regulation

Regulation is tricky. On the one hand, standards should be idealistic and be a benchmark for services to aspire towards. On the other, a regulator needs to be pragmatic, which means recognising that the resources necessary for improvement are often not available and are outside the power of the individual service provider. Knowing where the…

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The problem with Angola

In his time as Minister for Health, the former Taoiseach Brian Cowen once famously referred to the Department of Health as ‘Angola’. This was due to the number of political landmines that were ready to explode in the face of unsuspecting Ministers. The quip is regularly trotted-out by political reporters on the appointment of a…

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A systemic failure on an incredible scale

Paul Mulholland  Has there ever been a construction healthcare project as mired in delay and controversy as the National Children’s Hospital? From the time the hospital was announced, a shadow has hung over the development. The need for the hospital was first put forward in 1993, when the RCPI proposed a single tertiary children’s hospital…

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Values cannot be viewed in isolation

It is hard to imagine the role of the HSE being highlighted in such a way should the Olympics ever come to Dublin. The institution is so derided that barely a flicker of dissent was raised when the former Minister for Health James Reilly announced that the Executive would be dissolved in the near future and replaced by a group of hospital Trusts. This plan was never implemented and the HSE continues to lurch from one crisis to the next, as emergency department overcrowding and hospital waiting lists hit record highs.

The recruitment and retention crisis makes it clear that working for the HSE is just not an attractive option for many medical professionals. And staff who do not choose to emigrate or take up posts in the private sector are working within a service that is over-stretched and under-resourced. It is no wonder that burnout has become a major issue and has been highlighted at numerous clinical meetings this year. The HSE’s own data also shows there is a morale problem. The results of its first staff survey in 2015 showed more than two-thirds of medical and dental grades were experiencing high levels of stress. Only 18 per cent of HSE staff believed the health service was genuinely interested in the wellbeing of its employees.

It is within this context that the HSE’s Value in Action programme was established. The aim of the programme is “mobilising staff and empowering them to lead the changes that we need to truly build a better health service”. Basically, this boils down to helping staff take more pride in their work and showing them how their behaviour affects others. It is designed to ensure staff feel valued and appreciated for the work they do. These are commendable goals. But an investigative feature in this issue of the Medical Independent asks serious questions about the costs and structure of the programme and how it quantifies success. Moreover, is it even possible for such an initiative to succeed given the deep-rooted problems within the health service? Our columnist Dr Paddy Barrett recently wrote that mindfulness classes were not the answer to staff burnout. The only way the issue can be solved is through institutional change. It is likely morale in the HSE will continue to be low if hospitals are not resourced to do the work they need to do. The NHS captured the imagination of the nation when it was created in 1948 by providing a world class health service that was free for everyone. The Government and the HSE need to start providing a service Irish people can be proud of if the aspirations of Value in Action are ever to become a reality.

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Getting clinical audit right requires time

Clinical audit is needed for health services to measure errors in care to help ensure they don’t reoccur. Given its importance, the manner in which an audit compiles and assesses data has to be beyond reproach. An audit that is not fit-for-purpose will not tell you whether the health service is fit-for-purpose.

Examining mortality data is perhaps the most sensitive area of clinical audit. Determining the exact cause of death is not easy, especially if the patient had significant comorbidities, which is the case with many elderly patients. And judging whether that death was avoidable or preventable can be onerous work.

The NHS recently established a programme focused on publishing data on and learning from avoidable deaths. At its launch, the UK’s then Health Secretary Jeremy Hunt hailed the move as ushering in a new era of transparency, with the NHS becoming the first health service in the world to introduce such an initiative.

For a structured judgement review (SJR), which is the process the NHS is employing, multiple reviewers are necessary to get a reliable judgement on determining whether a death is avoidable. A SJR is conducted as a first-stage review by a consultant not directly involved in the patient’s care. If any phase of care has a low quality rating, then these records go for a second review. The second review is usually undertaken by a group of senior figures in the Trust, such as the medical director and chief nurse. It is at this stage that a judgement is made as to whether the death was avoidable. Even after these steps, it is sometimes difficult to determine if a death was avoidable, due to inadequacies in the case notes and other issues.

It is clear why such a process could be difficult in the Irish hospital system, suffering as it does from a chronic deficit of senior clinical staff. The Director of the National Perinatal Epidemiology Centre in Ireland, Prof Richard Greene, told this newspaper that data collection is burdensome and there is a lack of protected time for clinical audit. Also speaking to the Medical Independent, Clinical Lead and Chair of the National Audit of Hospital Mortality (NAHM) Governance Committee Dr Brian Creedon cast doubt on the ability of Ireland’s health service to employ SJRs in the way they are being implemented across the UK, precisely because of the lack of staff, especially consultants.

Currently, the NAHM uses standardised mortality ratios (SMRs), which is a method of determining excess deaths across the sector. SMRs have been criticised as a performance measure in relation to the quality-of-care overall, because issues such as coding practices and the number of deaths occurring in one hospital compared to another all have significant impacts on the data.

However, no tool is perfect, and many experts agree it is important to use a mix of measures to assess the quality of a health service. Whatever these measures are, staff need to have the time necessary to ensure they are utilised correctly so that data produced stands up under scrutiny and is sufficiently robust to drive change.

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A health policy collision course?

In healthcare, there will always be internal tensions and competing interests. Often, these are at a funding level, whether it is a choice between financing primary or secondary care, or deciding to build a new emergency department in the west rather than in Dublin. Sometimes the tension is much more fundamental, and becomes a contradiction. Take private health insurance as an example. Government policy is to have a strong health insurance market. Lifetime community rating was introduced in May 2015 in order to incentivise younger people to take out health insurance. The scheme was established by the then Minister for Health Leo Varadkar. At the time, Mr Varadkar said the increase in the number of people holding health insurance, most of whom bought policies just before lifetime community rating came into force, was to be welcomed.

Fast-forward two years to the publication of the Sláintcare Report in 2017. Sláintecare, which was built upon strong cross-party agreement, promises nothing less than the “transformation” of public health services. If the strategy is fully supported, and this transformation occurs, what will the impact be on the private health insurance market? The likelihood is that the demand for health insurance will be greatly reduced if the public service starts functioning properly. Moves are already occurring to remove private practice from public hospitals and the report from the Independent Review Group to examine the area is eagerly awaited. The full implementation of Sláintecare would mean this is only the first step in the strategic prioritisation of public over private healthcare.

The ad hoc development of the Irish healthcare sector has given rise to a complex mix of public, voluntary and private hospitals, along with different funding models. The previous Government’s plan to introduce a universal health insurance framework was a failed attempt to merge the strong private health insurance market in Ireland with the public sector. Sláintecare offers an alternative path to creating a more equitable health service  — one that is not nearly as accommodating to private health insurance companies. The question is whether the Government, or a future Government, has the will to continue on the potential collision course it has begun.

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Reduction in sepsis-related deaths is to be welcomed

This has sometimes been a source of frustration for those working in healthcare, who feel the positive impact they are having on patients’ lives is not being fully acknowledged. At an organisational level, the HSE is involved in numerous quality improvement initiatives through the clinical programmes, which seek to raise the quality of care across the healthcare system. The improvements achieved by these programmes are made more admirable given the continuing resource shortages that affect the sector.  So it is worth noting the recent announcement by the HSE that there has been a 20 per cent decrease in sepsis-associated hospital deaths in the last four years.

The announcement was made at the launch of the HSE 2017 National Sepsis Report at Dublin Castle. The reduction in deaths can largely be attributed to the National Sepsis Programme’s drive to increase awareness and implement better practice. Central to the reduction has been the Sepsis Management: National Clinical Guideline, which was quality-assured by the National Clinical Effectiveness Committee and launched by the then Minister for Health in November 2014.

Internationally, approaches to sepsis management care based on early recognition of sepsis with resuscitation and timely referral to critical care have reported reductions in mortality from severe sepsis/septic shock in the order of 20-to-30 per cent.

There were 16,312 cases of sepsis documented in adult inpatients in 2017, with an in-hospital mortality of 18.4 per cent, representing a 3 per cent decrease in mortality since 2016. Overall, there were 18,411 cases documented between adults, maternity and paediatrics, including SIRS of infectious origin, sepsis and septic shock (the old sepsis-2 definition), and their mortality rate was 16.8 per cent.

While there are still improvements that can be made, the progress is heartening to see.

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Transparency — what’s sauce for the goose…

An important finding in the report is that Dr Gabriel Scally did not see evidence that any issues with CervicalCheck were brought to the attention of the Minister prior to April 2018, when the Department of Health first became aware that a legal case was scheduled for hearing.

When the controversy first broke, there was uncertainty as to how much the Minister knew about the Vicky Phelan case and the failure to divulge audit results. The Government must feel some relief that the report states there was no cover-up and that the controversy no longer threatens to bring about an early election.

However, Dr Scally does refer to how the absence of information from the Department of Health and HSE allowed conspiracy theories to flourish. Any discussion of inappropriate communication by medical professionals should include an examination of how the Government and State agencies inform the public about their health service.

One of the chief criticisms directed at the Taoiseach Leo Varadkar is that he is too concerned with perception, or to use a word currently in vogue, ‘optics’.  Take the leak to the press the day before the Scally report was released. Two major news outlets revealed that the Scally report did not recommend the establishment of a Commission of Investigation. This was the first the women and families who had been calling for such a Commission heard about the recommendation. A communication failure occurring on the eve of the publication of a report on a scandal that developed as a result of communication failure is typical of how the affair has been handled from the beginning.

And if we are talking about transparency, it would nice if there was more candidness from Leinster House about waiting lists. The latest statistics published by the National Treatment Purchase Fund show over 700,000 people are currently on hospital waiting lists, which is a new record. Most of these are on outpatient lists. Mr Varadkar insists the health service is moving in the right direction, as there has been a small reduction in the numbers waiting for inpatient and day case procedures. But the current threshold target of 18 months is way in excess of what a proper goal for a functioning hospital system should be. According to the most recent edition of the Euro Health Consumer Index, waiting times in Ireland are among the worst in Europe and anybody with a cursory knowledge of the public Irish health service would agree.

If the Government is going to compel doctors to be more transparent and open, it should look in the mirror first.

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