Interviews

The views of a President

Paul Mulholland speaks to President of the RCPI Prof Mary Horgan about the links between undergraduate and postgraduate medical education, solutions to the doctor recruitment and retention crisis, and the future challenges facing the College

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Past, present and future of St James’s

St James’s Hospital is embarking on a new period of its existence as any visitor to the Dublin 8 site cannot fail to notice. However, as development of the National Children’s Hospital (NCH) continues, a new book looks back on over three centuries of fascinating medical history on the site.

“The hospital has developed an awful lot over the last 40 or 50 years,” Prof Davis Coakley told the Medical Independent (MI) when asked why he thought now was a good time to write a new history of the hospital.

Prof Coakley was formerly a consultant physician in St James’s Hospital and Professor of Medical Gerontology in Trinity College Dublin. He is the author of numerous books on medicine, the history of medicine and Irish literature.

“This seemed an opportune moment to look back on what has been achieved [over the last half century]. But also, St James’s has a heritage a couple of hundred years before that,” said Prof Coakley who has co-authored The history and heritage of St James’s Hospital, Dublin (Four Courts Press) with his wife Mary.

Ms Coakley studied English and Italian in University College Cork and has worked with her husband on a number of literary and historical projects.

“It has taken time to explore that background; because it was founded in 1703, we needed time to do research. We were doing research for a number of years and it has all come to fruition. It really is the end of a fairly long process of research and writing.

“My wife Mary has been involved in a lot of books with me. We wrote and edited together when we were quite young. She has helped me with books over the years. This time this was such a big undertaking, I could not have done it on my own. So Mary was very involved in the research in particular and editing, improving the quality of writing etc.”

Tradition

Prof Coakley said that during his time in St James’s there was something in the caring tradition of the hospital and the physical buildings themselves that sparked his interest in the past.

“When I came back to St James’s from the United Kingdom as a young consultant, I was amazed at the standard of care that older people were getting from nurses,” he recalled.

“The nurses were so committed to care for older people. Why that came about interested me. Of course a tradition had developed [over time], particularly in St Kevin’s where a lot of the poor were old and without any kind of resources and the nurses had a very dedicated and caring attitude towards the patients.

“This maybe interested me in the history and tradition and made me kind of determined to try and build on this great tradition of care, with modern facilities for older people.”

During his time at St James’s, Prof Coakley was a leading force behind the establishment in 1987 of the Mercer’s Institute for Research on Ageing in St James’s and which later became the new Mercer’s Institute for Successful Ageing (MISA). 

“The other thing that interested me when working there was, of course, the actual physical facilities in the hospital, which were mainly old workhouse buildings,” he said.

“The history of these buildings interested me greatly.”

The history of St James’s Hospital stretches back to 1703 when legislation was passed to build a workhouse on its site. Just under 30 years later a foundling hospital was added to the workhouse. The opening chapters of the new book discuss this period and the pitiful treatment of abandoned children.

Foundling hospital

When asked what was the most interesting period to look into during the research, Prof Coakley said it was these difficult early years.

“Well, I suppose I found the original period to do with the foundling hospital most interesting, I knew very little about that,” he told this newspaper.

“We still had buildings from that period from the 18th century, quite a number around the hospital and I’ve worked in those buildings and always wondered what they were used for. I wondered what went on there.

“The whole story of the foundling hospital is very interesting. It was set up originally because infants were being abandoned in doorways and along the banks of the canal after birth.

“In 1703 a workhouse had already been established in St James’s, it was quite a fine building. It was built just outside the gates of the western entrance to the city. It was to get people going in from Galway and the south-west. If people didn’t have enough means of support, rather than being allowed into the city to beg, they were put into the workhouse. At the time beggars were perceived as a major nuisance [by the authorities] and it was used to move them off the streets of Dublin.

“Then after 30 years the [abandoned] children issue was becoming more pressing. So they decided to also use the workhouse for the care of abandoned infants.

“It was probably not a very wise decision and there were a number of scandals during the following century.”

Prof Coakley said that a foundling hospital was different than our modern sense of a hospital.

“It’s an institution to look after abandoned infants, who were usually found in the door of the church or wherever. It wasn’t an infirmary in the modern ways we would think of an infirmary. It wasn’t a hospital in the sense of a modern hospital,” he explained.

When the foundling hospital was closed in 1829 the buildings were used to house the South Dublin Union Workhouse. The workhouse played a crucial role during the Great Famine, giving shelter to thousands of starving people.

“What happened was that in and around the 1830s the foundling hospital had gone through several changes and a lot of children were now developing into teenagers and being sent out as apprentices around the country,” said Prof Coakley.

“It was becoming very costly for the government to maintain it. In the end they decided to close it and say these infants were now being cared for in other institutions, etc. It was finance in the end that made them decide to close it, not the scandals that had been going on for the previous hundred years.

“The building was empty in the 1830s. In 1840 when they decided to set up a workhouse system here, similar to the one they set up in the UK, despite a lot of objections, the buildings of the old foundling hospital were used for the new South Dublin Union Workhouse.

“That was established in 1840, it was just five years before the onset of the Famine. It played a key role in a positive and negative way during the Famine years. Lots of people who were starving sought refuge there and the number went up to 3,000 people in the institution at the time, which was built for far less.”

Then after the Famine a major cholera outbreak (see accompanying extract on page 14-15) added to the public health woes for medical authorities.

Bravery

Doctors were at the frontline during this outbreak and some lost their lives. Reading the account from Prof Coakley’s new book, it is hard not to be struck by the comparison to contemporary events, such as doctors who have lost their lives in Ebola and Zika outbreaks. Prof Coakley also sees the parallel.

“Yes, it is comparable to Ebola, in that doctors really put their lives at risk,” he said.

“It was the same then. These doctors exposed themselves to risk all the time, some of them caught cholera, it happened in the South Dublin Union, but it happened throughout the country to lots of doctors.”

According to Prof Coakley, a famous physician from the period “described the mortality rate of doctors treating things like a cholera epidemic as being twice that of officers in the field of battle… for these doctors there was no such thing as their pension after that, their families were left without any support in very dire circumstances.

“They did put their lives at risk, and they were very heroic people.”

It was not until the early decades of the new State that the institution that we now recognise very much as St James’s finally took shape.

“The [new] State was in a very poor state,” said Prof Coakley.

“There were an awful lot of slums in Dublin. The people were living in just dire poverty. There wasn’t a lot of funding around to remedy the situation quickly. But the State was concerned that the very poor were not receiving treatment and [about] those living in the tenements who had no resources.

“They were anxious to develop a municipal hospital, which would focus on the care of the very poor. St Kevin’s started to emerge as a concept before the Second World War.

“Then after the war, they began to knock [down] several of the very old buildings around the campus of what was the South Dublin Union and refurbish others, so they created what became known as St Kevin’s Hospital and this was a major hospital.

“Again with doctors working extremely hard. There were not a lot of consultants or surgeons or physicians, but they worked long hours and gave a service to people who otherwise would not have a service.”

Future

In 1971 three of the oldest voluntary hospitals in Dublin, Mercer’s, Sir Patrick Dun’s, and Baggot Street Hospitals, amalgamated with St Kevin’s to form St James’s Hospital. Over a very short period of time St James’s Hospital became the largest teaching hospital in Ireland.

Currently, St James’s Hospital campus is entering a new era with the building of the NCH.

“It’s ironic really, part of the development of the children’s research institute will be situated next to the infirmary of the foundling hospital, which is still standing,” according to Prof Coakley.

“It is a beautiful Georgian building. So it’s kind of gone full circle from where the treatment of children was not what we would have hoped for, to a situation now, where it is going to be a world leader in terms of the care of children.”

He also mentioned the maternity care history that was in existence when St Kevin’s was open at the site.

“Now it is moving back 40 or 50 years later, it will be a state-of-the-art maternity hospital – so the wheels of history are fascinating when it comes to the history of St James’s.”

See http://www.fourcourtspress.ie/books/2018/st-james-hospital-dublin/ to purchase the book online. 

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Reflections of a CIO

Prof Martin Curley joined the HSE in April with an employment history involving large-scale information technology (IT) transformation at multinational corporation Intel.

He led the creation of the company’s Mastercard Advisors Digital Capability, established a global network of 15 Intel IT innovation centres and helped to transform Intel’s research reputation in Europe.

His move to the public service at the HSE Office of the Chief Information Officer (OoCIO) is challenging, however, despite this experience.

Like other parts of the HSE, the Office is trying to stay afloat in the face of inadequate funding and staffing.

Stay left; shift left

Prof Curley is keen to make headway quickly in improving the HSE’s IT infrastructure, and has already developed a new strategy called “stay left; shift left”.

Under the umbrella of Sláintecare and the overall national e-health strategy, ‘stay left; shift left’ aims to transform the Irish healthcare service by using technology to keep people out of hospital.

The term ‘shift left’ was first coined in Intel, where there was an original strategy of the same name that aimed to find solutions to provide the highest quality-of-life at the lowest possible cost, Prof Curley explained.

When he began his role at the HSE, he then adapted the strategy, with the help of his team at the CIO Office, to include a focus on keeping people well.

“The philosophy of the healthcare system needs to change from making sick people better,” Prof Curley said.

“That, of course, is very important, but ideally we would want the centre of gravity to move to keeping people well first and then if you happen to get sick or have an accident we have technology-based solutions that can help take care of people better, cheaper and faster.”

Prof Curley noted that Ireland is at a unique point in time where there are multiple ‘disruptive’ technologies occurring simultaneously.

“In the past there were the railroads or the internal combustion engine and each of those drove significant disruption, but now we have cloud, mobile, artificial intelligence, the Internet and other disruptive technologies and this is accelerating the pace of change,” he said.

“One of the things that needs to happen in terms of the effectiveness of the digital transformation is that it’s done in a managed way, rather that just a complete free for all.”

The ‘stay left; shift left’ strategy aims to deliver transformation in a more managed way using technology.

“‘Stay left’ is about using digital technologies to keep people well and ‘shift left’ is about if you happen to be sick or have an accident we can use digital technology to move you as quickly as possible from an acute setting to a community setting to ultimately being treated in the home,” he explained.

“We look at four different characteristics of innovation that get us to ‘stay left; shift left’: Looking for digital innovations that reduce the cost-of-care, “improve quality-of-life”, and improve the clinician’s experience.”

These characteristics are the aims of all HSE clinical care programmes so the strategy is linked with existing organisational objectives.

“What we’re advocating with “stay left; shift left” is kind of an overarching digital innovation agenda for healthcare in Ireland. We think it could become the equivalent of Moore’s law. Moore’s law became the innovation strategy for the semi-conductor industry and basically all the players in the ecosystem, everybody aligned around the same goal,” Prof Curley stated.

“Rather than digital innovation happening in a sporadic way or by osmosis, we are able to direct and orchestrate it a bit better because we are trying to find solutions that align with this idea.”

Bluedrop Medical

According to Prof Curley, the HSE is actively looking for innovative technologies that align with the strategy. One example is Bluedrop Medical in Galway.

The company has developed a foot ulcer detection device that could transform diabetic management through early detection.

There are 10-to-11 diabetic foot amputations in Ireland every week. However, he said this figure could drop significantly if the company’s technology were adopted by the HSE.

Bluedrop Medical has developed a cloud-based solution where individuals with diabetes would weigh themselves daily using a scales.

The scales would take a picture and measure the temperature of the foot, sending this information to a cloud for analysis by healthcare professionals.

Prof Curley highlighted there is a strong correlation between the temperature of the foot and possibility of developing a foot ulcer.

“This would be early detection before an ulcer develops and would be a very good example of “stay left; shift left” implementation,” he said.

The technology is merely one of many candidates for implementation, but could be successfully adopted though the HSE Quality Innovation Corridor Programme in the future.

“The trick is how can we lower the barrier for innovation and how can we encourage the ecosystem to innovative with us so that we all, collectively, can improve much faster,” he said.

The strategy is in the “early stages” at present, but the idea has been shared with organisations such as IDA Ireland, Science Foundation Ireland (SFI) and Enterprise Ireland.

According to Prof Curley, Enterprise Ireland is announcing a small business innovation fund to help the HSE find solutions that align with the new strategy.

Meanwhile, SFI has new funding aligned with the idea, encouraging organisations to come up with solutions to keep people well and get them home from hospital as soon as possible, he said.

Prof Curley spoke at the RCPI’s annual St Luke’s Symposium at the end of the month on the topic of digital technologies and their impact on healthcare, and outlined the new strategy to delegates.

Resources

Compared to other similar organisations, the HSE Office of the CIO is significantly under-staffed, under-funded and under-resourced.

The deficits undoubtedly create immense challenges for the Office and Prof Curley is seeking more staff and funding in 2019 to alleviate pressure. 

“Compared to benchmarks the percentage of IT spending as a percentage of overall funding is low,” Prof Curley confirmed.

“Similar organisations are spending 3.5 to 4 per cent of their total budget on IT and for the Office of the CIO we’re spending around 1 per cent of the total budget on ICT. So we are making the case for 2019 to have a significant increase.

“We’re confident the capital funding will increase in 2019 but we also need to make sure expense funding goes up as well. Typically for every one euro of capital funding that you put in you need to budget in subsequent years 20 per cent of that for expense funding to maintain and operate the new systems that you deploy.

“It’s all very well having the capital funding but if you don’t have the resources to deploy the solutions then that’s an issue.”

The Office, due to a lack of HSE staff, relies on partner organisations like Deloitte and KPMG to assist with projects.

The Office has about 275 permanent staff. Adding contractors, the total staff number comes to around 400, Prof Curley said.

Some 49 staff positions approved in recent years have been filled but the Office is still “considerably under-weight” when it comes to staffing, Prof Curley stated.

“We have a huge amount of projects we’re managing so if we get commensurate increases in capital funding then we also need an increase in headcount so we can deliver the projects,” he said.

An analysis of staff numbers required has been conducted. Usually large healthcare organisations have up to 3.5 per cent in IT, but the HSE has about 1 per cent or less of the overall headcount working in IT, Prof Curley said.

“Arguably, based on benchmarks we would need to more than double staff.”

“One of the key things we’re looking at is to see how we could augment those resources in the estimates for 2019, but also exploring how we could partner with external companies; for example, Dell, Microsoft and IBM and how we could augment our resources by doing some strategic partnering,” he said.

“We’d like to make it so that for new college graduates, the Office of the CIO becomes an attractive place for them to work; the opportunity to do high-quality work and make a difference at the same time…We need to be able to attract the right kind of talent to work in our organisation.”

EHR

The Office’s flagship project is implementation of an electronic health record (EHR) for every person who comes into contact with the health service.

A HSE business case for the introduction of an EHR across the healthcare system is finally due to be approved before the end of 2018, two years after it was first submitted.

Approval is required for the business case in order to allow for a procurement process to commence for the development of an EHR at the new National Children’s Hospital (NCH).

Prof Curley said a pre-procurement market engagement seminar already undertaken had resulted in a supplier briefing with over 100 companies.

The new NCH, due to open in 2022, will be the first hospital in the country to implement an EHR.

“The implementation of the electronic health record is a major aspect of Sláintecare and is kind of the equivalent of the electrification of Ireland. What electricity did for Ireland, it’s that kind of change we’re seeking. It’s a very significant and big change that needs to happen,” he said.

Future

By the end of his five-year term, Prof Curley would like to have achieved and completed the first EHR implementation in the new NCH before further rollout continues in other hospitals.

He would also like to see “clear evidence that the ‘stay left; shift left’ strategy has transformed healthcare in a number of ways” and improved the lives of Irish citizens.

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Making no bones about advancing athlete health

Dr Pat O’Neill is a Consultant in Orthopaedic and Sports Medicine who works at the Mater Private Hospital in Dublin, runs the sports injury clinic at Cappagh National Orthopaedic Hospital, and lectures in orthopaedic sports medicine at Trinity College Dublin.

But for readers of a GAA persuasion, he is perhaps primarily known for his unmatched success with Dublin football. A key member of the legendary back-to-back All-Ireland-winning Dublin squad of the late 1970s, Dr O’Neill went on to manage the Blues to Sam Maguire glory in 1995, making him one of the select few to have earned All-Ireland medals as both player and manager.

Dr O’Neill’s unique insight into sports injury and sports medicine on and off the pitch makes him an ideal spokesperson for the ‘Mind Your Bones’ campaign being run jointly by the National Dairy Council and Cappagh National Orthopaedic Hospital in advance of World Osteoporosis Day on 20 October. It is an area he is more than familiar with; while the risk of bone injuries is part of playing sport, in some cases, osteopaenia or osteoporosis is a major contributory factor, he says.

“We see stress fractures and quite often, there is an underlying issue there in terms of bone health — maybe it hasn’t progressed to osteoporosis, but there is certainly an osteopaenia component to it. Then when you put the additional activity loads on it, the bone fragility comes into play and its doesn’t sustain itself for these repetitive activities,” he explains.

“I’ve had very little in terms of bone injury at any stage in a sort of fairly extended career. I have no doubt it was put down to drinking about two pints of milk a day. It is far better than those faddy sports drinks, for multiple reasons.”

””

Dr Pat O’Neill

While osteoporosis is a disease that predominantly affects females, particularly those post-menopause, Dr O’Neill says this does not mean men are protected.

“It has been an issue with regard to jockeys and it brings to light the whole issue surrounding their nutrition. Of course, that would bring in the dairy component of it as well, because the jockeys are tending to try and make a certain weight, as it’s a weight-restrictive sport. Their nutrition sometimes suffers on the back of that, and particularly any kind of nutrition that might involve weight gain. There would be this misperception that dairy products, because of their fat content, would increase weight, so they are not taking them and then because of that you have these deficiencies in calcium and vitamin D developing, leading to reduced bone density — maybe not to the level of osteoporosis, but it’s not optimal bone health.”

Bones are at extra risk in any high-impact sport, he adds. “Jockeys fall off horses and with any of the contact sports as well, you need good strong bones. Apart from the stress injuries, you need good strong bones to endure some of the acute bone injuries like fractures, as opposed to stress fractures, which is really a repetitive injury.”

Amateur participants

Dr O’Neill won’t be drawn on the most memorable injury he has come across, just to say it was in “the most high-profile” players, but he is also keen to emphasise the risks of injury in people for whom sport is a hobby. The increasing popularity of marathons, triathlons and ‘Ironman’ contests is sending far more people to his clinics with serious injury than in years past.

“These are people with high participation. They might not be considered elite athletes, but it can be a very important part of their lives. Probably the most common one in terms of bone are the stress fractures, or the bone stress conditions. They particularly affect the shin bone and the foot bones, also the hip bone. The hip bone is a particularly problematic one; that’s a major injury which can sometimes require interventional treatment and surgery if it’s not detected and dealt with early.”

One issue he isn’t reticent about discussing is overtraining, or “burnout”, which has been a hot topic within the GAA in recent years, as well as in other sports. Dr O’Neill chaired the taskforce on player burnout for the GAA over a decade ago and he says this continues to be a problem within the Association.

“It’s not a great term, ‘burnout’, but it is one that was used because it was one that the general public understood. With burnout, you can look at it from three main areas. There is the over-training component of it — more training does not mean one will get better; there are optimum levels in getting that balance right, so there is the physiological component of the over-training. That’s really what the burnout refers to,” he explains.

“There is the psychological component of it as well, similar to chronic fatigue, but it’s basically an over-training syndrome. Of course, combined with that over-training syndrome, you then get the over-use injuries, which logistically would come about again because of the high intensity level.”

Particularly vulnerable are younger elite players, mainly in the 17-to-22 year-old age group, says Dr O’Neill.

“A young male doesn’t reach maturity until they are 19, females about 17, but they are quite often the ones who are playing with multiple teams, at multiple levels. They can be overloaded and sometimes you find them competing in more than one sport and they haven’t reached skeletal maturity.”

The findings of the taskforce in 2007 were unequivocal; burnout was a serious issue that needed to be urgently addressed by the Association. Since then, certain restrictions have been put in place — for example, young players can no longer play at both senior intercounty level and under-20 level.

However, overuse injuries remain common in the younger cohort of players, states Dr O’Neill. One study showed that the ratio of training sessions to matches was an onerous 13:1, which Dr O’Neill describes as a “total imbalance”.

He comments: “The focus is to try and play more games and try reduce the training schedules. It’s more interesting and satisfying for the individual and it makes far more sense spending all this energy and activity, and the pressure on the musculoskeletal system on the playing field rather than the training field. The whole thing is to retain people to keep exercising right through their lives and not discourage them because of these issues that can evolve at an early age.”

Head injury

Concussion is another hot topic in sport. The precise long-term consequences of a blow to the head, and the links between concussion and brain damage, are still to be clearly elucidated by medics and researchers, but Dr O’Neill maintains Ireland is ahead of the game in this area.

“There is a big involvement in equestrian sports here, and in this you are dealing with speed, you are dealing with large animals, obstacles. In our contact field sports — hurling, football, soccer and rugby — they are heavy physical sports, executed with speed and agility, and the potential is there for collision and head injuries. Ireland would be considered one of the leaders in the awareness of this and in dealing with preventative measures.”

Dr O’Neill notes that concussion is now a huge issue in American football, with research showing an increasing number of retired NFL players who have suffered concussions have developed memory and cognitive issues, such as dementia, Alzheimer’s, depression and chronic traumatic encephalopathy (CTE). A number of legal cases have ensued.

“I think that has sort of woken up a lot of others to look at it from a preventative perspective rather than dealing with it when it occurs,” he notes.

Closer to home, Dr O’Neill is concerned at what he terms the “darker side” of supplementation and the growing prevalence of anabolic steroid use within sport, fuelled by their easy availability online.

“I really don’t think it’s very prevalent in this country, certainly based on the history to date, but there is concern about certain medications being used. I’m referring particularly to the likes of anabolic steroids and human growth hormones. The problem is that in the Internet age, these are readily available now. They are illegal of course to use, but that doesn’t stop them coming into the county and being available. Most of these are prescription drugs and they should only be prescribed for specific health reasons if there is a requirement.”

Dr O’Neill maintains his place on the GAA Medical, Scientific and Welfare Committee, one he has held for over 22 years, but is adamant that his current role is primarily as “an observer and supporter of Dublin football”. Thus, the last question has to be about the current Dublin crop and their stunning four-in-a-row achievement. Are they the best Gaelic football team he has seen?

“I think history speaks for itself; they are a fantastic team and they play very attractive football. They are such an impressive bunch of athletes and footballers and they have a great team ethos. They are extremely well managed by a former player, Jim Gavin, whom I managed myself, and he is ably assisted by Jason Sherlock, Paul Clark and Mick Deegan. Jim’s attention to detail, his use of sports science, sports medicine, exercise physiology, sports nutrition and sports psychology; it’s fantastic the way he is able to use it all. I hope that doesn’t sound seriously biased!”

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