Healthcare has begun to nudge its way into the political debate as candidates and parties respond to demands for reduced waiting lists and better services. Consultant Orla Hardiman outlines what she thinks needs to happen
The health services are in need of reform. Those of us who work in hospitals are all too familiar with the long waiting lists, overcrowded clinics, anxious patients, overburdened staff and an exodus of some of our best and brightest from the public sector into lucrative positions. They go overseas to jobs with better pay and promotion prospects, or they remain in Ireland and are enticed into the relative comfort of private medicine or industry, where the job description is defined, merit is recognised and performance rewarded.
The combination of chaos and inertia that is endemic within the hugely bureaucratic health board services makes it almost impossible to deliver a consistent level of high quality, flexible and responsive care. Those practitioners who remain within the public system, both at professional and administrative level, risk becoming burned out and sceptical about any initiatives, strategies or reforms being possible within the present system.
A thorough review of the entire health service is required, while attempting to maintain and improve existing services. From the perspective of this practitioner in the hospital-based speciality of neurology, there are three clear dilemmas health strategists face in providing quality care at an affordable price:
Funding, delivering and developing services that have not been externally evaluated.
Effective assessment of what services are actually delivering.
Catering for the competing requirements of a geographically accessible service for all, while in tandem encouraging the development excellence within speciality services.
The overall long-term restructuring of hospital-based services requires a long-term plan. This should start with a fundamental redefinition of how healthcare is delivered and measured. The days of the omniscient and omnipotent single-handed hospital-based consultant operating in isolation are long gone. There is an increasing recognition of the necessity of medical specialists to sub-specialise. This necessity has led to the development of centres of excellence in particular specialities.
Until now, however, the development of such centres has been driven primarily by the appointment of individual doctors with specific speciality training, but without the expressed mandate to develop a speciality centre. Centres have developed because doctors with sub-speciality training provide a sub-speciality service. To date, there seems to have been little or no attempt to develop a national plan that is responsive either to the overall health needs of the population, or to the sub-speciality requirements within particular disciplines. The strategies in cardiovascular medicine and oncology are notable but limited exceptions. This absence of effective planning has led to the costly fragmentation of secondary and tertiary care. From my perspective, there is little evidence of arrangements for the co-ordination of service delivery at national level. Equally important, there is no forum within the administration of hospitals to provide technical or financial support that would help conduct a systematic measure of the quality and outcome of the service we provide.
Recognition of this problem has prompted a series of initiatives by the Health Research Board to encourage research in health services. However, those engaged in service delivery are often so overloaded with clinical work that it is difficult to find time or energy to formally compete for research funding. Mechanisms to translate the outcome of such research back into healthcare reform need to be developed. The challenge is to find a way to measure whether the care that we provide is having a positive effect on the health of the population that we serve. Such outcome measures must be valid, reproducible and relevant to the Irish population. The validation of our service can then be used to promote speciality-specific models of care. Other countries have developed such instruments of measurement that could be modified and made relevant to specific specialities in Ireland. We have started a systematic review of services within neurology at our hospital, but regrettably, there has been no financial or technical support available for this to date.
The concept of a "model of cares" contains an implicit recognition of the value and importance of other clinical professionals. In neurology, these professionals comprise the multi-disciplinary team, and include specialist nurses, psychologists, physiotherapists, occupational therapists, speech and language therapists and others.
The contribution of non-physician professionals has been traditionally undervalued in Ireland. Their career structure is such that many reach the peak of their earning capacity within 10 years of qualifying, and there is a significant attrition rate from public service of skilled specialists as a result. Both delivery and measurement of health-related outcomes require a substantial contribution from clinical professional specialists, and review of their career structures should be viewed as a priority.
In general, the discussion surrounding healthcare reform centres on two main topics: the delivery of services within the primary healthcare sector (general practitioners), and the reduction of the number of patients on waiting lists for specific procedures within the acute hospital sector.
The latter represents an apparently easy way to measure whether our health system is delivering. The number of patients currently waiting for procedures is calculated, and their length of time on the waiting list measured.
While this method gives some insight into procedure-based medicine and surgery, it is primarily a reflection of the current shortage of available hospital beds and theatre facilities. Reform is clearly required to increase the number of beds for non-emergency operations and procedures.
However, this measure gives us no information about those patients who do not need an admission to hospital. Most of the 400,000 people with neurological disability fall into this category. Their ongoing health problems are best served by out-patient management. Reforms that include the purchase of care from the private sector or from overseas make little sense for these patients.
The care required is based on the development of teams of professionals, with each member of the team bringing a specific and particular sphere of expertise to the management of the condition.
Multi-disciplinary teams are rare in the private sector. What is arguably needed for the population as a whole is a planned, evidence-based integrated holistic approach towards management.
This includes the hospital-based team and the community-based service working in partnership, with the patient tapping into the expertise of a motivated multidisciplinary service with established methods for generating individualised care plans.
The role and value of the voluntary organisations should also be acknowledged and developed. The core principles for the development of neurological services have been outlined in the three-volume Standards of Care for Neurological Disability, recently published by the Neurological Alliance of Ireland. Such principles could be readily adapted for any other chronic illness.
What we need is a true reform of our health service. This is a long-term project that extends well beyond the lifetime of the next government.
Investment is required to develop instruments of measurement within each speciality that focus on both medical outcome and quality of life.
An overall strategy catering for the needs of the population as a whole is required, that can be administered through the regional health boards. The following would be a good start:
Centresof excellence to be developed and maintained where there is evidence that they provide better outcomes. Concerns about access to be addressed by improving the infrastructure for bringing people to hospitals.
Cross-referral between health boards containing different speciality services to be the norm, without the imperative of having all speciality services within all health boards.
Practitioners within hospitals to devise audit systems demonstrating the value of their interventions and services, both at in-patient and at out-patient level.
Extensive investment to be made in the development of multi-disciplinary teams with individual care plans being generated for individual patients.
Liaison programmes to be put in place between hospital- and community-based services. Administrative bodies such as the regional health boards and the hospitals within their remit to demonstrate their commitment to such developments.
Dr Orla Hardiman is a consultant neurologist at Beaumont Hospital in Dublin