OPINION:Public-private conflicts of interest are part of the problem at Tallaght hospital, writes TOM O'DOWD
WHEN RTÉ broke the story of the X-rays fiasco at Tallaght hospital in Dublin on Monday night, I experienced a great sense of relief. I have been concerned about general practitioner access to radiology in Tallaght for a number of years. I was astonished to hear at an internal hospital meeting in April of 2009 that there were “thousands of X-rays” unread in the X-ray department. This figure was quantified a few weeks later at about 20,000. I was surprised at how many people knew about the X-ray problem internally but felt they could do nothing about it.
Also, for a number of years, I have been concerned about Tallaght’s handling of my referral letters. When I see a patient who needs further investigation, I write a letter and dispatch it to the appropriate, named, consultant. These can be cases of suspected cancer, neurological disease, ear, nose and throat, eye disorders.
Increasingly over the last five years patients began asking if I had heard anything from the hospital about their referral. A phone call to the hospital would reveal that nobody knew anything about it and it must have got lost in the system. Frequently I would rewrite the letter only to find that this one fared no better.
A middle manager in the hospital told me in February 2009 that there were “two years worth of GP referral letters lying unopened” in an office. My GP colleagues said they knew things were bad and getting worse but they did not realise the scale of the problem. The hospital has had someone working on this over the last 15 months but we have never been told what has been done and patients have not been informed.
In April 2009, I wrote the now famous letter to Lyndon MacCann, the chairman of the hospital, to alert him to the fact that the hospital was exposing patients to terrible risk by not handling GP referrals and X-rays properly. As is well-documented, I never received a reply.
I told a variety of people over the last 15 months of the situation regarding X-rays and GP referral letters, including consultant colleagues, GP colleagues and senior management in Tallaght. I have not endeared myself to colleagues in some areas of the hospital. I notified the Health Information and Quality Authority (Hiqa) in April 2009, who responded promptly to my confidential enquiries and set about exploring the situation. It seems that the size of the problem has been significantly downplayed and it will be the duty of the investigative team to see if the correct information was available but not provided to the Hiqa team.
Radiology has been one of the areas of hospital medicine that has been under-resourced. When new consultants are appointed they inevitably place more demands on existing laboratory and radiology facilities. When Tallaght hospital was opened, there were 57 consultants and, I think, four radiologists. Ten years later there are more than 160 consultants and about six full-time radiologists.
An additional factor in my view is the privatisation of radiology and the conflicts of interest that operate among radiologists. Some public hospital radiologists also operate competing off-site practices in other institutions.
It seems to me that private radiology can work well and I have previously proposed that all radiology in hospitals should be outsourced with hospitals and GPs buying radiology on behalf of their patients. I think hospitals could rent space to radiologists who could own their own machines. This would get rid of many of the conflicts of interest that plague radiology, especially in teaching hospitals.
In Tallaght, with the increasing number of consultants, it is inevitable that the GP requests were placed at the back of the queue. As long as GPs are excluded from the governance of many hospitals and ignored by management it is inevitable that radiology, and other investigative services, will be allocated to those shouting loudest. It is well-known internationally that where GPs have reasonable access to radiology fewer patients are referred on to hospital.
Radiology has become increasingly reliant on information technology and Tallaght was one of the leaders in having what is called a PACS system, where all the images are digitised. It is my understanding that this system points up the number of unread X-rays at the end of the day. It will be up to the investigative team to see if this system was activated or otherwise.
The lack of proper handling of GP referral letters means long-term risk exposure for the hospital is the significantly greater problem. Even if it is now sorted out there are many patients who have had to wait far longer than they should.
If I write a letter to a named consultant on behalf of a patient, I expect that person or someone under his/her guidance to act on it promptly. This too needs to be part of any investigation into Tallaght’s activity. Patients who suspect that their timely referral for undiagnosed serious illness was not handled properly have reasonable questions to ask.
Tallaght will not be able adequately to defend this side of its practice for several years to come. This means that resources will have to be put aside specifically to investigate such cases. This money will have to come from patient services. Are any of our hospitals any different in their handling of GP referral letters? It is generally a black box without adequate operating procedures and a wide tolerance for “lost in the system” excuses.
Tallaght has been bad but other hospitals now need to look at their systems and reassure GPs and patients that their system is robust and effective.
I have been asked why was I, a GP, was the only one who was blowing the whistle, even if to deaf ears? I applaud the individual who alerted Fergal Bowers of RTÉ to the situation in Tallaght.
I am glad that I have been able to provide a paper trail because I have no doubt but that my complaints would become a casualty in all of this. I have spoken to consultant colleagues in Tallaght and more widely who have supported me in what I am doing.
However, they have told me of their helplessness in trying to change the culture – and some good doctors have given up trying to change the culture in Tallaght.
Why are high-achieving grown men and women with fine university educations and highly specialised training afraid to speak out?
Hospital staff, like kids in the playground, are often controlled by cliques and peer pressure. Senior nursing and medical staff need to be engaged in management at all levels. The Medical Council Guide to Ethical Conduct and Behaviour (2004) states “doctors have an obligation to point out deficiencies to the appropriate authorities and should not yield to pressures for cost-savings even if it means acting against the interests of patients”.
The charter for Tallaght hospital does not allow for general practitioners on the board. I spent six years on the board of Tallaght hospital through the graces of the Adelaide Hospital Society, who have always supported me in bringing forward issues from primary care.
Tallaght hospital is a fine facility with many dedicated professional staff whose morale I have further dented by these revelations. Many are glad that I have spoken out. It is a tragedy that they don’t feel able to use their own voices. The hospital now has to find its direction, engage with its community and begin the big job of restoring public confidence in what is its mission in life.
Tom O’Dowd is professor of general practice in the department of public health and primary care at Trinity College Dublin, and at Tallaght hospital. He is also a general practitioner