What is a health service for? It was a question that suggested itself many times during 2015, a year when the interests of patients and staff were all too often in conflict.
The obvious answer is that a health service is there to provide care for patients, and this is the way the system works most of the time.
Despite often difficult working conditions, medical and nursing staff consistently win high praise from patients for their efforts to provide high-quality care with a human face.
It is when things go wrong and patients and their families are dissatisfied that problems arise. This was amply illustrated with the publication this year of the report into Portlaoise hospital by the Health Information and Quality Authority (Hiqa).
The report laid bare how badly women who had lost babies in the hospital were treated when they were looking for answers.
It found the health system failed to recognise the problems at Portlaoise over many years and failed at all levels to act meaningfully. But it was the findings about how patients – women who in many instances had just lost their babies – were treated that struck home with many people. One woman was told in a hospital corridor her baby had died; another was reprimanded for crying after her baby’s death.
Others were told their baby was stillborn, only to discover in documentation or reports that this was not the case. Parents in some instances had their baby brought to them in a metal box on a wheelchair covered with a sheet and pushed by mortuary staff.
The report described a lack of compassion, empathy, dignity and respect.
Cut funding
The women whose experiences were at the centre of the report initially thought they were alone in their struggles to get more information about what happened.
They might have remained that way, and been unsuccessful, if it was not for some chance link-ups and the assistance they got from a patients' advocacy group, Patient Focus.
The Portlaoise scandal prompted concerns about standards in other maternity units and various investigations and individual cases reviews were started.
These either haven’t been completed or were dealt with on a private basis with the families concerned, so it is difficult to say whether the concerns expressed have been adequately investigated.
In one case, the death of a baby was reviewed and it was found there was no requirement for further investigation, yet a coroner's inquest later resulted in a finding of medical misadventure and an apology from the Health Service Executive (HSE).
A key recommendation of the Hiqa report on Portlaoise was the setting up of a patient advocacy service to work on behalf of patients and families seeking answers about death and injury.
Towards the end of the year, Minister for Health Leo Varadkar announced a package of reforms, including a National Patient Safety Office and the kind of advocacy service recommended by Hiqa.
Yet this was pretty late in the day, given the Programme for Government promised in 2011 that a patient safety agency would be established. It will fall to a new government to implement Mr Varadkar’s commitment.
In the interim, the Government has cut funding for many of the patient advocacy bodies, which survive on a shoestring. Some are dependent on funding from the private sector, including the pharmaceutical industry.
Over at the Medical Council, the sometimes conflicting interests of patients and doctors was evident in another forum. The public hearing-of-fitness to practise inquiries into doctors has been underway for more than five years now and public inquiries into the conduct of nurses began more recently.
While only a minority of cases proceed to public hearing, those that do have often provoked considerable controversy. The stakes for the medical personnel under inquiry are enormous and the process tends to be lengthy and stressful, so it is hardly surprising there have been calls for reform.
‘Show trials’
HSE director general
Tony O'Brien
, perhaps with this and the Portlaoise controversy in mind, has hit out at what he sees as a trend toward “show trials of health professionals” and says “an air of guilty until proved innocent has developed”.
This is certainly a view held by many doctors, who frequently blame the media for giving the impression that medicine can be error-free and that adverse incidents result only from doctors’ errors.
Seen from the patients’ side of the fence, the ground looks entirely different. Numerous individual cases have shown how hard it is for a patient to get a hearing, how long it takes for a proper inquiry to be carried out and how stressful the process is.
Often, it seems as though the system is pushing people down the legal compensation-seeking route because all other avenues have been closed to them.
We are promised change: open disclosure; a duty of candour; faster inquiries; the new patient agency promised by the Minister.
As a quid pro quo, the fitness-to-practise regime may be modified to allow for the anonymising of doctors’ name in public hearings in some cases.
Given the enormous impact an even minor finding can have on a doctor’s name when ventilated in the media, this may be a necessary price to pay for the introduction of a healthier relationship between patients and the people who treat them.
