OPINION:Bowel cancer testing farce is symptomatic of a far greater malaise in this creaking system, writes DR MUIRIS HOUSTON
THE HEALTH service is the next financial crisis waiting to happen. Healthcare is likely to implode in the same way the banks and the financial system did. Yet we seem, as a nation, content to sleepwalk our way into a similar meltdown of our public health system.
Something of an overstatement, perhaps?
Not if we draw some analogies: transpose the Health Service Executive (HSE) for the pre-meltdown commercial banks and the Health Information and Quality Authority (Hiqa) for the Irish Financial Services Regulatory Authority.
In his report on the major failings of the banks and the regulatory system, Patrick Honohan referred to the inspection by the regulator of the top developer borrowers at five financial institutions in 2007. It showed up a series of failings in the banks’ risk management systems. Each bank had no idea of the overall borrowings of its developer clients. Instead of triggering alarm bells and some swift action, the regulator did nothing.
We are fortunate that Hiqa takes its regulatory role more seriously than the financial regulator did. It has responded to concerns about patient safety at Ennis and Mallow hospitals and triggered inquiries into the running of both facilities.
But it is operating in a vacuum. The HSE withholds information from it and fails to carry out its recommendations. The HSE culture is to “carry on regardless”, which may be amusing in the setting of a comedy series but is nothing less than reckless when people’s lives are at stake.
So health has a responsive regulator, more than the financial system had. But how reassuring is that? Not much if the focus of the rest of the health system is to find ways around Hiqa, with the HSE constantly batting it away like a cow’s tail might swish at a fly.
Meanwhile, the Department of Health, policymaker to the HSE’s care-deliverer, watches ruminatively from the sideline.
The recent revelation that colonoscopy waiting times have lengthened once again is a perfect example of how the HSE goes round in circles.
Susie Long died unnecessarily of bowel cancer in 2007. Despite an appropriate referral by her GP, the significant delay she experienced in obtaining a colonoscopy in the public health system meant her illness was incurable at the time of diagnosis.
Following a public outcry, Mary Harney promised no one would wait more than four weeks for the test.
Yet here we are three years later and the Irish Cancer Society has figures showing 1,073 people are now waiting three months or more for a life-saving test. This is a 25 per cent increase in the figure for December 2009.
In 2008, there were 2,216 new cases of bowel cancer recorded in the Republic. We do not know how long each person waited for a colonoscopy. But we can be certain that if there are 25 per cent more people waiting in excess of three months for the definitive diagnostic test, then a significant number of those currently waiting will have a delayed cancer diagnosis that will alter the treatment options available to them, leading to unnecessarily fatal outcomes.
There are enough endoscopists and specialist units throughout the State for a six-week “referral to test” threshold for colonoscopy to be met. It does not take rocket science to make this happen.
Give the task to your average manager in the commercial hotel sector and he would have a robust system up and running within six to eight weeks. But the centre of inertia that is the HSE has utterly failed in this simple managerial task.
Right across the medical spectrum, similar failings are compromising safety and putting lives at risk. They are being hidden by an endemic culture of fudge.
What to do? About 10 years ago, the NHS in Britain faced similar problems. It responded by setting up a clinical governance support team. Effectively a 12-person “special forces” team, it descended on poorly performing hospitals and dysfunctional health services, taking managers and clinicians firmly by the hand until the problems were sorted out.
Coincidentally, some people resigned, perhaps unable to adjust to a new reality. However, services improved with a renewed focus on patients’ needs.
Prof Aidan Halligan, an Irish doctor who almost became the first chief executive of the HSE, was the head of this “special forces” team at the time. He has spoken of the evasion tactics employed by those most resistant to change. Writing in the British Medical Journal, Prof Halligan said of the poor leadership uncovered by the UK Commission for Health Improvement: “There were cliques and factions among groups of staff, management was ineffective, staff with concerns about standards of care were marginalised or worse, adequate systems were not put in place, and the service was not seen through the patients’ eyes.”
It has got to the point where we need some special forces of our own if we are to avoid a collapse of the public health service.
One solution may be to recruit a team from abroad to work within the HSE. What may sound like a similar brief to Hiqa is in fact very different; Hiqa can regulate from the outside but is weakened by the bluff and evasion of HSE culture.
And while such a team cannot tackle the myriad problems that beset the system, it can move on a small number of key services. We can reasonably expect a ripple effect as stories of an uncompromising approach to problems filter out to other parts of the health system.
As is often the case when special forces are deployed by the military, it is with a view to securing a beachhead.
However, we must still face the reality that the HSE is a failed entity. It simply does not have sufficient managerial capacity to function like a 21st-century health service.
Until such time as politicians confront the need for a radical restructuring of the public health system, it remains in danger of collapse.
And just like the banking collapse, we cannot say we didn’t see it coming. There will be nowhere for the Minister for Health and the board of the HSE to hide.
Dr Muiris Houston is the Irish Times health analyst
