We need a mandatory regulation regime in hospitals and clinics to ensure the systems that doctors are working within are subject to scrutiny, writes Dr John Hillery
Several weeks have passed since the death of Pat Joe Walsh in Monaghan hospital. His death and the reported circumstances that surrounded it evoked many reactions: compassionate anger for the man and sympathy for his family; dismay that the circumstances, as reported, could conclude with a man losing his life; questions about our health service and its capacity to answer our needs.
Legitimate questions have been asked as to what the response of doctors should be in such a situation. However, each specific clinical situation is too complex to be judged without knowing the details and the exact choices available to those involved at the time.
I have been asked for my comments on the possible ethical issues raised relevant to the actions of individual doctors in circumstances similar to those hypothesised to have existed on the night Mr Walsh died. I do not believe any comment on the incomplete story that is available would be helpful or appropriate.
The Tánaiste has commissioned an investigation into the events. The Medical Council will examine the report of that investigation when it is made available.
Whatever the final report tells us, a space must be created for an informed discussion on health service provision. No matter how great the resources available, they will always be stretched by the evolution of medical practice.
Whatever the resources provided, risk will never be totally removed from the therapeutic relationship. To minimise risk, we know decisions must be made regarding the geographic spread of services.
The focus of medical education is now on the development of competencies. We train doctors to be able to do what is required of them in their speciality. For those of us who have finished our training, modern practice rightly demands that, once trained, we continue refresher education to remain competent.
Another key factor is not widely known outside the profession. For doctors to remain competent in the delivery of any treatment, they must be carrying out a minimum number of such treatments. This means that, no matter what resources are available, if there are only a small number of patients presenting with a condition it is difficult to maintain competence in the treatment of that condition.
It is impossible for every practitioner to deliver the full range of therapeutic interventions, and for every hospital to do so either.
The ability to deliver a service with minimal risk is dependent on many factors. It is misleading to suggest that every part of the country can have a hospital that can safely deliver all the interventions that patients need. It is possible to establish a national healthcare system that ensures the maximum appropriate service and minimises risk.
To develop such a system requires a rationalisation of the types of activity in certain hospitals. It also requires an infrastructure that can reassure people that geographical distance will not put them at risk if they fall ill. A template exists for such a system.
The long-term question for patients is how they are to know if their needs can be met by an individual doctor and by an individual hospital?
The medical profession has taken a lead in developing a system that will assure patients of the competence of individual doctors. The introduction of the system (known as competence assurance) requires changes in legislation.
The current legislation that governs doctors is 28 years old, inflexible and out of date. It records the competence of doctors at the end of their training and does not revisit this unless legally sustainable questions are raised about a doctor's practice after that point.
The medical profession has asked for change and has outlined the system required. The Tánaiste has promised a new medical practitioners act that will allow the regulation of doctors to adapt as medical practice changes. The new act will allow the introduction and implementation of competence assurance structures as planned by the profession through the Medical Council.
These structures will assure patients that the doctor responsible for their medical needs is currently competent. Doctors will be required to record and report on their continuing medical education activities, to audit critically their own practice and to meet independent peers to discuss their practice and plans for personal professional development.
The processes will involve the input of people who are not doctors. If the practice of any individual doctor gives cause for concern, a more intense assessment of their practice will take place. This will be carried out by trained assessors, both medical and non-medical.
It is acknowledged that this system of competence assurance will further challenge resources and individual doctors. Nevertheless, the profession believes these processes are an essential development as regards the wellbeing of patients.
Doctors in Ireland are self-regulating and take this privilege seriously. Self-regulation has been granted to professions on the basis that the issues require expertise available only within the profession. Self-regulation assumes that the profession sets standards for its members and will ensure that it will deal with any member who falls below the standards.
The Medical Council is the body that implements self-regulation for doctors in Ireland. It has medical and lay members. Regulation is carried out through the registration of doctors, through accreditation of medical education, by giving ethical guidance to the profession and through the fitness-to-practise procedures that examine complaints about individual doctors from various sources.
It is striking that no such mandatory regulation is in place for hospitals and clinics. While the Medical Council can call doctors to account for their activities, the systems in which doctors work are not subject to the same level of scrutiny.
Arrangements must be put in place to ensure "system competence" similar to the system being developed for doctors. This would be of greater value to patients than the development of "league tables" or such seemingly populist but morale damaging processes.
The model exists in the form of voluntary health service accreditation processes. A mandatory system would promote appropriate allocation of resources and the development of a system of patient intervention compatible with evidence based best practice.
The Medical Council would be a keen participant in any rational debate as to how this might be brought about.
Dr John Hillery is president of the Medical Council