Frank Keane knows a thing or two about waiting lists. He pores over them regularly as joint head of the HSE’s surgical programme.
Last week, the figures set off alarm bells. Half a million people were on waiting lists. The number of adults waiting longer than six months for inpatient and day case care has spiralled to 26,838 – up from 9,643 when the government took office in March 2011.
In recent years – and assuming you weren’t benchmarking progress against the government’s ever shifting targets – waiting lists have been going in only one direction. Up.
Keane sees no reprieve in sight – largely due to to the absence of any significant and fundamental change within the system.
Fine Gael recently proposed having a dedicated fund of €50 million a year to reduce waiting lists. Keane’s view on this is simple: it won’t work.
“Every time this has been done, there is a short-term dip before they rise once again. The data shows this very clearly,” he said.
Keane said he has tried to change the system from within, but recognised that his impact was limited. “It is a very frustrating environment to work in. Things are done to suit the political cycle – not for what is best for the country.”
Flawed waiting list initiatives
We have had various waiting list initiatives in the health service. The first was in 1993. The National Treatment Purchase Fund was set up under Fianna Fáil in 2004. Fine Gael then set up a Special Delivery Unit (SDU) in 2011.
“There have been repeated government-led initiatives that invariably involved transferring patients over to the private sector. These initiatives have cost the state somewhere between a quarter and half a billion euros, money that has been lost to the public system without any infrastructural payback,” said Keane.
‘It is a short-term fix, not a long-term solution. Indeed, after each initiative the situation always deteriorates. And yet this is still advocated as a solution by some political parties. It was Albert Einstein who said that insanity was doing the same thing over and over again and expecting a different result.
“Chris Ham from the UK’s King’s Fund [an English health charity that shapes health policy and practice] has stated that politics and policy work on different cycles, which results in short-term political initiatives getting in the way of the long-term policy commitments needed to deliver transformational change. Nowhere is that better demonstrated than in Ireland.
“Meaningful reform has always and continues to be dogged by short term-ism and local politics. After each new election we begin the new electoral cycle where a new political administration introduces a raft of new policies. For the first half of the cycle these are stumbled through often after questionable research – such as universal health insurance or co-located hospitals,” Keane said.
“Then for the second half of the cycle, after the realisation that these have largely failed, it becomes a matter of battening down the hatches and limiting the damage done prior to the next election.
“It seems that the whole administration, Department of Health and Health Service Executive, are caught in this unproductive and energy -apping vortex. Put bluntly, the health service of this country has not been well served by either our political or administrative systems.”
Keane, a former president of the Royal College of Surgeons in Ireland (RCSI), has seen this first-hand.
When he chaired the government’s expert panel on medical cards, he was struck by the revelation that Oireachtas members placed a weekly average of 560 telephone contacts and 615 emails as well as numerous parliamentary questions to the HSE.
Not only did this create a “massive burden of work for the service”, it also indicated “undue political interference in a service that should be relatively standardised and transparent”.
“Hospital and health facility planning in Ireland is often shaped and shepherded by the prowess of the local politician’s ministerial stature,” Keane said.
He said advocacy on health matters for constituents was clearly important to politicians, but that there needed to be “a responsible balancing of judgment as to the country’s interest versus their local interest”.
He said one of the biggest factors contributing to long waiting lists was not, in fact, a shortage of beds, but poor administrative planning, fragmented primary and community care, as well as poor access to diagnostics.
“Take back pain. It’s a common problem. Patients typically need to get an x-ray and an MRI. Yet, instead of being able to get those outside of hospital, GPs often have to refer their patients for an appointment with an orthopaedic surgeon who then has to organise the diagnostics,” Keane said.
The staff issues
He said change was also confounded by vested and sectoral interests including educational establishments, hospitals, health workers and trade unions.
“In a list of preferment, the best interests of the patient often comes low in the pecking order,” said Keane.
Doctors need to change the way they work, he said. The failure to do this is exacerbating inefficiencies, he said.
“Too many doctors are not doing a sufficient number of ward rounds. They are not seeing their patients often enough or planning their discharge early enough,” he said.
“Discharging patients early in the day allows beds to become available for another patient. Most hotels require guests to leave their rooms by 11 o’clock in the morning to make it available for another customer. Currently, our national hospital discharge rate by 11 o’clock is about 10 per cent. Theatres which use 12 per cent of hospital resources are, for various reasons, used extremely inefficiently,” Keane said.
A 2013 report showed that 56 per cent of patients admitted through emergency departments under surgeons did not require an operation.
Keane said a certain proportion of this figure (56 per cent) was understandable, as some patients might need a scan or observation, but that the figures clearly suggested that a large volume of unnecessary admissions were occurring. The same can be said for medical admissions.
This equates to tens of thousands of patients. It raises serious and very obvious questions around how well the beds we do have are being used.
“While recruitment of healthcare staff is a problem, the demarcation of professional roles is another serious problem,” he said.
“We are struggling to recruit theatre nurses at present and yet we cannot hire theatre assistants to plug that gap. Theatre assistants work very well in many other countries.”
The Irish Nurses and Midwives Organisation (INMO) is vehemently opposed to efforts to introduce theatre assistants.
There is no clinical evidence to suggest that having a theatre assistant replace a ‘circulating’ nurse in an operating theatre has any impact on patient safety, Keane said.
Privately, managers and surgeons who have spoken to this newspaper said the INMO’s position was about protectionism.
Put simply, if theatre assistants replace some nursing positions, then the nurses’ union stands to collect fewer membership fees.
Keane believes we need to explore newer ways of working with allied health and social care professionals such as physician assistants.
Structural change has a long way to go
Keane believes our political and administrative systems have been less than successful in the organisation of our hospital services.
The present government has organised the country’s 29 acute hospitals into six hospital groups (excluding children’s hospitals).
Keane said hospital groups make sense once a “finite, prescribed population is provided for” by its group of hospitals and their associated community healthcare organisations that work in harmony.
But as far as Keane is concerned, that is not happening as well as it should. He described the Ireland East Hospital Group as “a clumsy amalgam of 11 hospitals”.
The group extends from Mullingar to Wexford, and includes the Mater and St Vincent’s Hospitals in Dublin.
“It is also very hard to understand why we have nine community healthcare organisations (CHO) as against six hospital groups. It means that some hospital groups share or are associated with more than one CHO – and up to five in one case. This is hardly going to be conducive to coordinated, easily managed and comprehensible pathways for patients and doctors,” Keane said.
He believes we have “far too many acute hospitals” for a country of this size.
Many of our small rural acute hospitals are struggling to attract specialist doctors. This is of growing concern to Keane.
So too is our growing reliance on locum doctors – temporary medics drafted in to fill vacancies.
“It is not attractive to them [specialist doctors], as by and large their work will be general rather than specialist. In medicine we now have consultants who deliver about 30 major specialties and 90 sub-specialties. People have have got to understand that there won’t be sufficient volumes [of patients] for doctors to maintain their skills in some smaller hospitals.
“We did not have all these specialties years ago when the general surgeon and general physician did everything. We are still working within a system that has not adapted to changed times.
“People want their local hospital to be all things to all men. We simply cannot afford that. Not only can we not afford the expense, it can sometimes compromise good or safe contemporary practice,” Keane said.
“Critically, planned or elective care should be protected and separated from acute and emergency care.”
He said we would never solve the problems facing the health service without a radical change in thinking.
Managers within the health service were overly focused on directives and compliance targets coming from on high, rather than concentrating on the frontline.
Keane said there was no simple fix for the Irish health service, but that patients and taxpayers deserve better. “If there was a quick fix, it would have happened by now. Changing the system is a painstaking, detailed operational challenge that does not lend itself to the kind of big bold interventions beloved of politicians,” he said.
“Improvements in care should occur through many small changes which over time will help to deliver better outcomes and reduce variations and waste. The speed of change will depend not just on resource and commitment, but on sea changes in culture, attitude and governance.
“Tremendously good things are happening within the system, but they are being dwarfed by inefficiencies elsewhere. This is something we can change, but we badly need new strategic thinking and the development of long-term strategies with a ten to 20-year vision.”
Cross-party political consensus is needed, he added.
“We are a small island with a compact community and a committed workforce. It must be possible. Anything has to be better than the destructive, unrealistic manifesto wars we are faced with and yet another confusing spin on the political roundbout,” Keane said.
In next weekend’s Sunday Business Post, Frank Keane will outline key solutions to bring real improvement to the health service