Does the HSE get an unfair press?
YES:The HSE is not perfect, but most patients are actually happy with their treatment. Given the chance, the HSE can get to grips with its problems, writes Anthony Staines
THE HSE is the Aunt Sally of modern Irish life, always good for a rhetorical bash, and with a talent for presenting itself in the worst possible light. While I have nothing against good clean knockabout fun, there is a risk in taking the rhetoric too seriously.
The public seem to quite like the health services, and generally approve of the services they and their families receive. UCD's Cecily Kelleher and I did a survey for the HSE, in 2007. We used questions taken from similar surveys in other countries, and we found that people were generally satisfied with general practice (84 per cent), and rather less so with hospital inpatient services (67 per cent).
People felt that they were mostly treated with dignity and respect, and that facilities were generally acceptable. All was not perfect, but it was hard to reconcile our findings with the usual media presentation.
In fact, they are two sides of one coin. HSE has real problems, which go far beyond inept public relations. These problems have their roots in the continuing political failure to come to some clear decision about the role and scope of Irish health services, and the poor processes used to set up HSE.
Irish politicians have sedulously avoided making tough decisions about health services, and, in fairness, the electorate has let them get away with it. As a result, we have a badly configured hospital system, a very underdeveloped primary care system (that is general practice, and related services), and, overall, a very unfair service.
Access to care still depends on how much money you have. The public see general practice as the cornerstone of their health care, but primary care development is taking a back seat to co-location and other developments. Too much healthcare that could and should be delivered in the community is still provided in hospitals.
The Prospectus report recommended in 2003 that a single executive agency be set up, to run the health services. The idea was good but, in my view, the implementation was poor.
The transformation programme, whose goal is to ensure that everybody will have easy access to high-quality care and services that they have confidence in, and that staff are proud to provide, should have been in place by the end of 2003, rather than the start of 2007.
There have been many changes in administrative structures, but too little change in healthcare delivery - what front-line staff do. HSE is still critically short of managers, and, arguably, over-supplied with administrators.
But, what's past is done, and what matters now is delivery. HSE is making progress and is beginning to deliver some of its objectives.
There are more primary care centres; central services like finance and population health work better; staff training is getting better; information and financial control systems are improving; services in the smaller hospitals are being rationalised; cancer services may be drawn (or pushed) into larger, more viable units.
Things are still chaotic, but there are signs of recovery.
Of course, there are still problems - the co-location initiative may yet prove both expensive and futile; access to services for very common chronic diseases like high blood pressure, mental health problems and diabetes remains poor; equitable access to services has yet to be agreed by the politicians.
Crucially, HSE may not get the extra resources it needs to make the change to a more patient-centred, primary-care-led system. This transition will be expensive, but if it is to succeed it will have to be funded.
There is a more immediate threat. There are many calls for further major structural changes in HSE. Most call for a return to some equivalent of the former health board structure, with more local political involvement.
What would happen if Mary Harney, or her successor, gave in to this pressure and announced some large-scale restructuring of HSE?
We can learn from the English experience. The NHS has had many major reorganisations of its administrative structures since the early 1980s. The effects of these have been studied, and are surprisingly small. Each reorganisation produces a period of near-total paralysis of decision-making for about two to three years.
The effect is something like a child potting out a plant, and then digging it up every week just to see if it is rooting.
All of the HSE's problems will not be fixed by the transformation Ppogramme, but it is a start. There is hope for the future.
The current structures are not perfect, but any wholesale change in structures will just postpone the tough decisions for another three or four years, and I do not believe that we need any more delays.
HSE is just recovering from the shock of its birth and may be starting to work. Give it a chance and let it bloom!
Anthony Staines is professor of Health Systems Research at the School of Nursing, Dublin City University
NO:The HSE consistently brings bad publicity on itself. In the absence of proper accountability, the media has to highlight the real problems, writes Eithne Donnellan.
PICK UP a newspaper any day of the week or tune into any radio or TV news bulletin and there's almost inevitably coverage of some health service issue. Many will be the usual mix of stories about cutbacks, shortages of frontline staff or beds, equipment lying idle, a patient waiting hours in AE for a hospital bed, adverse events in hospitals, criticism of the outsourcing of services to the private sector, of money being wasted, of too much bureaucracy in the Health Service Executive, and of lack of accountability when things go wrong.
The HSE is constantly under scrutiny and it may well appear to some that the media is obsessed with bashing it, just for the sake of it. But consider for a moment why in reality the organisation is never too far from the headlines.
It is a relatively new organisation with responsibility for a massive budget almost €15 billion of taxpayers' money this year for which it has to be held to account.
Apart from its basic responsibility of having to provide safe and timely services our families all need and use, the HSE has also been tasked with implementing massive changes - to the way services are organised, to the way staff work - with reaching targets and with getting better value for money.
Many of the stories in the media are essentially holding the HSE to account for the way it is going about these tasks, which is essential in a new era where the HSE board meets behind closed doors, unlike in the old days when the press could attend health board meetings to report on decisions being made in each region as they happened.
When one looks at the health stories that dominated the news agenda over the past 12 month, the ones that stand out relate to the number of times patients attending several different hospitals in Portlaoise, Galway, Cork, Limerick, Drogheda and Navan had cancer misdiagnosed. The Fitzgerald report into the HSE's handling of the crisis in Portlaoise found systemic weaknesses in management, confused and contradictory communications and too many distracted people running around the HSE not knowing what their role was.
The Health Information and Quality Authority investigation into Rebecca O'Malley's misdiagnosis found there were often long delays in getting responses to letters sent within the HSE management system, if a response was issued at all.
The impression gained was of a system that delayed or avoided difficult decisions, it said.
Or just look at what happened when the HSE had to contact about 4,600 people in the northeast to inform them their X-rays and CT scans were being reviewed after X-rays of six patients with lung cancer had been misread. Even though it has more than 100,000 staff, it hired a private company to dispatch the letters and some of them ended up going to the wrong people.
It's hard not to argue that often, when the HSE gets bad publicity, it just brings it on itself.
The chief executive of the HSE, Prof Brendan Drumm, and the Minister for Health, Mary Harney, regularly point out, whenever there are stories printed about mishaps in hospitals or patients waiting hours in AE, that satisfaction levels with hospital services are much higher among patients when independent surveys are conducted than one might gauge from coverage of hospital-related issues in the media.
One found that 90 per cent of 344 inpatients interviewed rated their experience as excellent, very good or good.
Just 9 per cent described their experience as poor or fair. Furthermore, just 13 per cent of the 470 outpatients interviewed rated their experience as poor or fair in the previous 12 months.
It's true that thousands of patients get excellent treatment in our hospitals every year. But awful things also happen, and just because many patients are satisfied with treatment once they get into hospital and come out the other end unscathed, doesn't mean the media should turn a blind eye when some patients are dissatisfied and want to highlight what happened to them in the hope that lessons are learned.
Of course the media has an obligation to be fair and when improvements in services are announced, these too get coverage. For example, the recent award to healthcare staff at Dublin's St Vincent's hospital for coming up with a successful way of reducing long waiting times in its neurology department made it into a number of publications.
But stories about outbreaks of Clostridium difficile contributing to the deaths of patients in hospitals are regarded as bad press by the HSE at a time when it says it is taking steps to reduce healthcare associated infections by 20 per cent.
The bottom line is that if these types of stories are true, which they are, the public has a right to know. If nothing else, their publication may increase pressure on those in authority to act with even greater urgency to try and tackle them in all our interests.
Eithne Donnellan is health correspondent ofThe Irish Times