Restrictions proving unhealthy for Irish medicine

Last week, in the journal Science, Tony Blair wrote that investment in scientific research is a critical part of his strategy to modernise Britain and to equip his country for the next century. He announced the provision of an extra £1 billion of government funding for basic research over the next three years: "The science base is the absolute bedrock of our economic performance, generating the skills, knowledge, and technology that will maintain the United Kingdom's competitive edge in the global markets of the new millennium. That is why we are investing now."

If Mr Blair is right - and he is - where does that leave Ireland's "competitive edge", given the consistent failure of the State to take scientific research seriously? I wrote here last week about the importance of a science policy for the future of the Irish economy. There is, to be fair, some recognition at government level of the fact that the emigration of young Irish scientists, especially in the medical field, is a serious problem. A few months ago, the Minister for Health, Brian Cowen, set up a forum to consider ways of keeping "the cream of Irish doctors" within the Irish health system.

But there is as yet not much sign of a willingness to tackle a central part of the problem - the restrictive, hierarchical and innately conservative hospital consultant system.

Health policy experts have long recognised that the Irish system doesn't work. Five years ago, the Department of Health's then chief medical officer, Dr Niall Tierney, drew up a report calling for health care in public hospitals to be provided by qualified consultants rather than by junior doctors. It recommended that the ratio of consultants to junior doctors should be one to one. Five years later, nothing has happened and the ratio is still two junior doctors (2,700 in all) for every consultant (1,340) working in the public health system.

There is only one good reason for the number of consultants practising in the Irish system to remain so low: to keep the incomes from private practice of the present consultants artificially high. The economics are simple. Since the amount of illness is finite, the fewer consultants there are, the more each of them earns. Because the public salaries of these consultants tend to be a relatively small part of their overall earnings, the State saves little money by limiting the number of them.

One result of the restrictions is long waiting lists for public patients. Another is that, short of waiting for a consultant in their field to retire, top-class Irish medical researchers abroad have no posts to return to.

And a third is that there is no incentive for a consultant, having finally achieved a post, to keep doing innovative research. As one senior Irish doctor at the University of Pennsylvania, Prof David Kennedy, put it to me: "You have to do research to get a consultant's post in Ireland, but once you've got it, you don't have to do research to keep it. If anything, research is a disadvantage. It gets in the way of your private clinics, which is where you make the money, and it carries no financial incentive in itself."

He and anyone else I've spoken to who works at a high level in the American system agree on the basic requirements for creating a good structure of biomedical research. One of the most important is a rational career structure, where the best young scientists can, if they prove themselves in their own fields, gradually move up the ladder. In Ireland, the career structure, both for medical research and for biomedical science, is virtually non-existent.

There is hardly any place for the kind of doctor that is typical of the best American institutions, one who moves easily between the lab and the ward, bringing the experience of treating patients to the task of investigating scientific processes and vice-versa. The problem is that it is just this kind of doctor who represents the future of good medical practice and of the sort of biomedical technology that is going to be a huge economic driving force in the coming decades.

I talked to two young Irish doctors doing post-doctoral research in Pennsylvania, Dr Anne Burke and Dr Carmel Regan. Both are doing basic research, and both believe that the work they do in the laboratory will make them better at treating patients.

Neither especially wants to be a full-time lab researcher, but each feels that medical practice is much better when the practitioner understands the underlying process involved in the treatment. But what these women are doing is not typical of Irish medicine.

Dr Emma Meagher, director of the Patient-Oriented Research Programme in Pennsylvania, believes that this has a bad effect, not just on science, but on medical practice itself. "Here, there's constant contact between the lab and the clinic and the individual doctor has the ability to interact with colleagues on multiple levels. The Irish system, on the other hand, is rigidly hierarchical.

"Consultants tend to be absolutely dogmatic that the way they learned something, which might be 20 or 30 years ago, is the best way. There's a suffocating inability to see the bigger picture."

And within the universities, there is the same kind of problem. Prof Alexander Whitehead, who moved from Trinity College, Dublin, to a professorship of pharmacology at Pennsylvania, told me: "One of the key differences between the States and Ireland is that in Ireland, the intermediate level between someone who's done a Ph.D. on the one hand and someone who has a permanent position in a university or a clinic on the other is completely missing.

"There's enough intellectual capital to train people to very high levels. But there isn't the physical and financial infrastructure to hold on to them. Given the fact that in 10 or 20 years, all modern economies are going to be based on cutting edge technology, that makes no sense."

None of this is going to change unless the change is led by the State. There has to be a coherent policy for science in general and for medical science, where Ireland has real resources to harness, in particular. Part of that policy has to be a long-term commitment of money for scientific research.

Much of that money should go to the development of new layers within the existing universities, institutes of technology and hospitals, into which the good young Irish scientists working abroad in world-class establishments can be attracted. Some of it should go to a belated attempt to forge real links between Irish scientists and multinational industries.

And some of it should be used to free up the hospital consultant system that has become such a serious impediment to the long-term health of the Irish boom.

Fintan O'Toole is based temporarily in New York.