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It’s all about trust

Mybe the first part of a long-term plan is to recognise just where we are today,” says IHCA President Dr Tom Ryan as he outlines what he thinks should be the policy priorities for the Minister for Health.

“Because unless we recognise how far behind we are today, there can be no realistic attempt to catch up with our international comparators.”

And the situation Ireland’s health service is now in is an incredibly challenging one, according to Dr Ryan. Echoing many of the points made in the recently-launched IHCA pre-Budget 2017 submission, he points to the significant cuts in health spending over the last decade, the demographic pressure with a growing population of over-65 year-olds, the lack of beds in acute services, obsolete equipment and a consultant recruitment and retention “crisis”.

In June, Dr Ryan, Consultant in Intensive Care and Anaesthesia at St James’s Hospital, Dublin, took over the IHCA Presidency from Dr Gerard Crotty, who had completed his two-year term. He is joined by two new IHCA Vice-Presidential appointments, in Dr Roy Browne, Consultant Psychiatrist, Phoenix Care Centre, and Dr Oisin O’Connell, Consultant in Respiratory Medicine, Mater Hospital, Dublin.

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Dr Tom Ryan: ‘It’s not just at an organisational level, consultants at an individual level are very upset'

IHCA consultants head to Kilkenny on the first weekend in October for the Association’s 2016 Annual Conference and there is much to discuss and debate, particularly the ongoing excessive pressure on the hospital system.

“When you look at the Irish population over the last decade, the population has increased by 3 per cent, but those who are over 65 years of age make up 12 per cent of the population,” Dr Ryan tells the Medical Independent (MI).

“That particular part of the population, although it represents only 12 per cent of the population, accounts for 50 per cent of all inpatient days,” he notes.

“Now, thankfully, there are more elderly patients in Ireland; it is just proof that people are living healthier and longer lives. This is a good problem to have. Rather than regarding it as a problem, it should be regarded as an opportunity here to provide more and better healthcare for more people, so they can continue to live longer.”

So coming off the end of over a decade in spending reductions, investment must now be to the fore, insists the Association’s President.

“A very significant increase in investment is needed. Our focus is on the acute hospital and mental health services, and it is clear that their budgets have decreased respectively by about 12 and 20 per cent at least over the last eight years at a time of substantial increases in demand,” maintains Dr Ryan.

Working in the field of intensive care, Dr Ryan has witnessed many of these challenges up close. Upon assuming the Presidency in June, he noted that he was “very concerned that the lack of intensive care unit (ICU) beds is putting patients’ lives at risk”.

Dr Ryan points out that the reduction in ICU beds in recent years “contrasts sharply” with the recommendations of the HSE-commissioned Prospectus Report.

“Prospectus recommended in 2009 that the number of ICU beds increase by 45 per cent immediately and double by 2020. These recommendations have not been acted upon.”

Capacity

Dr Ryan explains that during the period of decreases in health spending, “the number of inpatient and day-case patients treated increased by 282,000 per annum, an increase of over 22 per cent”.

“However, this increase hasn’t been sufficient to cater for the increase in demand from the population presenting to the public health system. Hence, we have waiting lists that are getting longer. We can’t match the caseload that is presented to the acute hospitals, because there aren’t enough beds in the system.

“We have one of the lowest number of hospital beds per head of population in the OECD.”

But despite the constraints placed on medical staff because of the cutbacks, much good work is still being done, says Dr Ryan.

“These beds are run very efficiently when you look at the fact that we have one of the shortest hospital stays among the OECD countries. And we run the hospitals at one of the highest occupancy rates of all OECD countries.”

Are consultants and others working on the front-line of the health service given enough credit for these successes?

“Well, I think these figures are not known widely; they are never discussed,” he says. 

“When you compare our number of acute beds to, say, France, if we were to have the same number of beds per head of population as France, then we might have to increase our bed capacity by about 4,000, which is about the size of six Beaumont Hospitals. That is what we need to play catch-up after what has happened over the last decade.

“Clearly, the Government does not have the money to do this today, but they will need to plan for this in the coming years, to increase the bed capacity in Irish public hospitals, by that order of magnitude.”

Planning

Dr Ryan points to the need for long-term thinking on a number of occasions during the interview.

The Dáil recently established a new committee looking at developing a cross-party consensus on a decade-long vision for healthcare.

“It is important to have long-term thinking,” agrees Dr Ryan.

“It is a great idea to have all-round buy-in into a long-term plan. But the first part of a long-term plan is to recognise just where we are today, because if there is not a recognition of that, then there will be no realistic attempt to allow doctors in Ireland to provide care for their patients to a level we would aspire to and to a level that would be regarded as an acceptable, contemporary, international standard.”

So what can be done? For Dr Ryan and the IHCA in general, what they describe as “breaches” in the consultant contract by the HSE have left a significant amount of anger and distrust. The issue is being played out in the courts at the moment and any possible future negotiations regarding a new contract seem unlikely with the legacy of distrust left from the last one.

“The breach of contract and trust by the HSE has not created a great work atmosphere for consultants in Ireland,” contends Dr Ryan.

“The discriminatory salaries that they introduced for the new-entrant consultants just compounded that error. The profession by and large has lost trust with the State and health service employers. The Irish health service is no longer competitive in recruiting consultants. In 2015, one-in-four advertised consultant posts received no applicants and a similar number of posts received only one applicant.”

But do individual consultants really experience this sense of “loss of trust”, or is it mainly felt at the level of negotiating teams from the IHCA?

“No, it’s not just at an organisational level, consultants at an individual level are very upset,” insists Dr Ryan.

“That was bad enough, but when that is combined with how they have cut the number of hospital beds, decreased capital expenditure and squeezed the system, there is certainly a feeling in the profession that they then scapegoated the front-line staff for the failures of a system that was under-resourced.

“I think in some ways, that caused as much distress as the breach of contract. It was one thing to breach the contract; it was another thing to blame us for a system that was under-resourced. The combination of those two factors undermined morale.

Abroad

“Now, to undermine our morale; that is bad enough in itself. But our NCHD colleagues watched what was going on and they just emigrated in response.”

Statistics from the Medical Council and other sources confirm the significant movement of Irish doctors abroad.

After his training in Ireland, Dr Ryan spent six years in the US, but unlike many Irish doctors nowadays, he came back to Ireland to take up a consultant post.

 “With the Internet and with the standard of medical education in Ireland, Irish doctors are highly educated and are employable anywhere around the world. Irish doctors in their 20s, by the time they qualify, they are fairly widely travelled and it’s not a big move for them,” he says.

“What keeps people in a job are their terms and conditions, including salary and other aspects of the work environment. To get doctors is difficult enough at the moment, due to the international shortage.  However, to get them to work in an under-resourced system where there aren’t enough beds, operating theatres and there aren’t enough endoscopes, there isn’t enough access to diagnostic imaging, is another matter. The combination of all these factors and more makes for an impossible workplace.

“And if you go abroad and are successful and work in an adequately-resourced healthcare system and are practising to the highest standards, then you look at the prospect of returning to an under-funded, under-resourced system in Ireland — you just are not going to do that.”

Leading members of the IHCA spoke at its recent pre-Budget 2017 submission launch of a “lost generation” of Irish doctors, who are leaving the island, possibly never to return.

“If you go abroad and you have a partner and children, you are not going to make such an important career decision and return to an employer that you just don’t trust,” warns Dr Ryan.

“If you can’t trust your employer, it’s a problem — and at this stage, I don’t think the doctors trust the State and the health service management. The other health professionals don’t trust them; I’m not sure the public trust them either. 

“It is very difficult to get someone who is working in North America in a well-resourced, well-financed healthcare system who is getting well paid and who has a social and family life to come back and work in the chaos that is Irish health.”

With the problems clear, what does Dr Ryan think the Government needs to do to address these matters?

“They have to recognise what the problems are. They have to recognise that the health system is under-financed and under-resourced and there aren’t adequate resources at the front line to deliver care.

“What I mean by that is that there aren’t enough beds in the system, there aren’t enough doctors in the system for the number of patients who are presenting to Irish healthcare at the moment.

“Unless we recognise the problems now, we have no hope of improving the system over the next 10 years at a time when the need for care and services will grow.”

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