Irish hospitals compare well to their French counterparts, says trainee hospital manager Guillaume Pradalié
Much is said about how good the French healthcare system is. However, it is far from being free. It is paid for by heavy taxes (10 per cent of GDP goes on health expenses, compared to 7 per cent in Ireland).
It may be a more equal system: taxpayers pay according to their income, and patients receive high quality care without regard to their personal economic situation.
But some things are not ideal. Trade unions, for example, have hindered many changes, and France is still striving to have major regional hospitals incorporate rural hospitals, whose low activity (especially in surgery) is a threat to quality of care.
Hospital managers in France and Ireland also have quite different backgrounds. In France, the Ministry hires postgraduate students or professionals for a base period of 10 years. It then gives them compulsory training in management, communication, law and accounts or business cases for 27 months before they start working at top management level.
In Ireland, however, the managers come from various backgrounds. While this provides for greater diversity, management training could be very beneficial for all health administrators. Most of the chief executives I met were good managers, but, as former accountants, it was only their personal interest in management that explained their commitment.
The lack of education in management for consultants and senior doctors is also a flaw in both our health systems.
However, Ireland sets a good example in a number of areas and is in a period of transition.
In Ireland, nursing has perhaps become more professionalised than in France. French trainee nurses still undergo a three-year apprenticeship while in Ireland the nursing curriculum was made 12 years ago into an undergraduate four-year university degree. Irish nursing has more of an academic career structure with opportunities for continuous advancement and personalised work plans. Nurses in Ireland also have a higher status among clinicians.
It would seem too that Irish management, doctors and nurses work more cohesively and with fewer demarcations. In both countries there has been a history of confrontation and distrust. Irish clinical staff, for example, would have more autonomy over a limited annual budget and would take more administrative decisions.
Neither France nor Ireland are as advanced as Britain, where for a long time each department has been led by a medical director and a manager who report to the chief executive.
Ireland already has a framework in which all three groups of stakeholders are expected to cooperate extensively and multidisciplinary workgroups are encouraged. France is lagging behind but has very recently instituted a British -inspired governance system where every hospital is divided into a few units, each led by a medical manager, a general manager and a nurse manager, who all report to the chief executive.
The biggest, most obvious challenge, it seems, is for Irish hospitals to improve their physical environment. Irish hospitals of all types vary considerably. There are new high-technology hospitals but, unlike in France, there are still old buildings with warehouse-type wards.
Gloomy lighting, stained floors, old furniture and a lack of private space are often evident, mostly in hospitals for older people.
While in essence the quality of care is more important than buildings, considering the elevated standards of care in Irish hospitals, the physical environment is the most pertinent issue. There is only so much that can be achieved in a poorly designed building.
I visited a number of hospitals in the Republic and Northern Ireland, both acute and community. There are some good memories: the new medical tower in Crumlin Children's Hospital, a children's hospice in Belfast and the new building at St Vincent's Hospital in Dublin.
Much attention is given to children, but why should the elderly often have to endure substandard accommodation?
An abiding memory is the visit to Dublin of US professor Roger Ulrich, whose championing of single rooms for all patients seems to have many supporters. He said single rooms were preferred by most patients and they enhanced infection control. They were cost effective and did not require more staff if properly designed, according to the evidence.
Prof Ulrich said single-bed rooms should be built for good visual access and family presence. Properly designed ward layouts and nurse stations reduce staff walking and fatigue, increase care time, and support respite from stress.
Hospitals designed to be quiet reduce stress, and improve outcomes for patients and staff. Exposure to daylight, nature and gardens lessens stress and pain.
Irish healthcare personnel are also seriously examining the Teaghlach, or household, model, in the care of older people. The household model wants to recreate home conditions for residents in what is effectively their last home. It is manifested by small units and communal areas.
If you provide for the dying you provide for everyone. Dying, death and bereavement issues are crucial in the modern hospital, accounting for much staff stress and family complaints.
There is a huge need for end-of-life education and training to bring about the cultural changes necessary to enhance the experience of those dying in hospital and their families. Irish experience proves that huge changes can be achieved through education.
When many Irish hospitals were run by religious communities, the staff had clear guidance on how to deal with death. As time went by, the culture around death, dying and bereavement sometimes changed. Death began to be seen as a failure by clinical staff. Increasingly this is changing.
In France a law obliges carers to involve the patient and the family and ensure that their wishes are implemented. However, while there may be a law, it is not always followed, indicating the difficulty in changing culture and practices. In recognition of this difficulty, and promoted by the Hospice friendly Hospitals programme of the Irish Hospice Foundation, 40 hospitals of all types have signed up to a major programme aiming to ensure that everyone has a caring, careful death.
Guillaume Pradalié is a trainee manager in psychiatric care. He has been on an internship with the Hospice friendly Hospitals programme