"Every system is perfectly designed to achieve exactly the results it produces."
If that is true, and I believe it is, the person who designed the Irish healthcare system has some explaining to do. But perhaps the picture isn’t as bad as it seems. As luck would have it, the healthcare system contributes very little to the overall health of the nation, by some estimates, as little as 10 per cent.
You might be surprised and possibly relieved to learn that those of us involved in managing and providing healthcare in Ireland have relatively little to do with how healthy you are. That is down to a potent mixture of genetics and social as well as other determinants of health. These include education, housing, environment, income, communities, society, family, citizenship, involvement in voluntary activities, and many others.
These factors have a much greater influence on your likelihood of living a productive and happy life into your old age than anything we can do for you with our healthcare systems.
As a practising physician, I haven’t helped you that much, but on the plus side, I haven’t harmed you that much either. When one looks at the macro- economic indicators, Ireland fairs quite well. In terms of the big picture stuff – our maternal and infant mortality rates and longevity expectations – we are right up there.
Being clever
So now that you know the GAA probably does more for your health than the HSE, what’s your problem with our healthcare system? Why are we spending €18.4 billion on it? What are we getting in return? Why are healthcare costs rising globally at a rate that even the most optimistic of us know is entirely unsustainable? The answer turns out to be a deceptively simple one: we forgot about our patients.
We were so busy being clever and developing costly treatments, facilities and systems, we forgot the first rule of any medical intervention: what does our patient want? What do they need? In short, what outcomes should we be trying to achieve for our patients, not for ourselves?
According to Michael Porter, economist and business strategist, and professor at the Bishop William Lawrence University at Harvard Business School, we all forgot about providing value for patients.
Porter and his colleagues at Harvard teamed up with the Karolinska Institute, and spent the past 20 years thinking about the global problem of spiralling costs and dissatisfaction with healthcare systems. They came up with this: it's all about providing value for patients around the conditions that are important to them. If we are not concerned with delivering value to our patients, we are failing in healthcare, no matter what else we are doing. It turns out we are failing on a massive scale, and not just in Ireland. No one has got this right.
However, this is the good part. Last month the International Consortium for Health Outcomes Measurement (ICHOM) met for the fourth year in succession, and 800 excited delegates heard the collective brains of Harvard and the Karolinska confidently announce that we have cracked the code on this.
Healthcare can be fixed if we listen to our patients, define the outcomes they wish to achieve, measure them globally on the same standardised scales and calculate the costs of attaining these outcomes, disease by disease, so we can calculate value.
This will transform healthcare, and drastically reduce costs (Porter estimates by as much as 20-30 per cent, which would to amount to €5 to €6 billion in Ireland alone.) It would put the patient back at the centre of everything we do. Not a bad result.
Though the idea sounds simple, it will be difficult to do. Although we are measuring loads of stuff in healthcare, we are not measuring the things that our patients are interested in. We can tell you a lot about the number of patients on waiting lists, but we can’t tell you what an Irish patient with prostate cancer wishes to get out of his treatment. Will he survive to see his first grandchild graduate? Will he be able to return to work or his favourite sport? Will he suffer incontinence or bowel trouble? Will his relationship be affected by sexual dysfunction? Although these are the obvious things we should be tracking, we are not. Why? Because we never took the time to agree common measuring scales on the stuff which matters to patients.
We haven’t figured out which IT system to use to make it easy to get the information we need and analyse the data, so we can present it back to our patients, and those who are commissioning the care from us. This is by no means an easy challenge to overcome. But, the process has begun. The Scandinavians are leading the way and the Dutch have already signed up to a value-based health strategy.
Change is coming and that is why our new Minister for Health has timed his entry perfectly. Now we have a roadmap that finally makes sense to all of us. Ireland has an opportunity to be in at the ground floor of this movement to change healthcare profoundly and, in the view of at least this healthcare worker, much for the better.
Frank Sullivan is professor in radiation oncology and director of the Prostate Cancer Institute.
