Mick Clifford: Health system reform will take a lot more than energy and ideas

David Cullinane: He demonstrated that he has a serious grasp of the health portfolio and is brimming with ideas. However, in his vision, there is no resistance to reform and it was a question of who in their right mind would even want to resist what he was proposing.

Here’s an informed verdict on the Government’s record on health from the main opposition spokesperson.

“The minister is relying on the same HSE, same culture, same structure and he’s expecting changes. When you’ve a long waiting time in emergency departments, it’s a symptom of what’s wrong with everything else.”

And on it went: “The Government has given no reason for confidence. There has been inefficiency, incompetence, maladministration, and false promises. We have seen people on waiting lists and on trolleys, not only to get into hospital but to see a consultant and get a diagnosis.”

So goes the damning verdict. Except, the verdict comes from different politicians, from different political planets at very different times.

The first lines were issued by Sinn Féin’s David Cullinane last Wednesday. The second paragraph came from Fine Gael’s Olivia Mitchell on November 11, 2003 — not that you’d know the difference. 

Nothing of substance in the area of emergency treatment would appear to have changed over the last two decades.

The depressing loop on which the Irish health service appears to exist was called to mind this week by a piece in Elaine Loughlin’s always interesting Tuesday political column. 

In the 'Politics headlines through history' slot was an Irish Examiner front page from 2004, which included a story under the headline ‘Report a political football, says Hanley’. The piece referenced the Hanley report published the previous year, which recommended the rationalisation of emergency departments.

The fate of that report, and what occurred instead, in some ways sums up the problems at the heart of the health service.

The plan was to downgrade the 40 emergency departments in hospitals around the country and create 12 centres of excellence. The logic was obvious, the science sound. There were statistics from abroad to show that health outcomes from such a system would be improved for everybody.

Despite that, resistance was fierce. Much of it was centred on Ennis and Nenagh, where the local hospitals were the first earmarked to be downgraded — and it wasn’t just local people in fear who came out against the plan. The opposition parties, led by Fine Gael at the time, were vehemently opposed. (Mitchell’s comments above were directed at the Hanley plan). Within cabinet, Tipperary’s Michael Smith was particularly vocal in resisting the change.

So it was that the Hanley report was largely shelved. 

Improving health is all very well as long as it doesn’t interfere with the perceptions, fears, and expectations on which politics thrives. 

Instead of implementing Hanley’s recommendations, there was, over the years, a piecemeal approach to the rationalisation of emergency departments. By 2016, the State had gradually reduced full emergency department cover from 40 hospitals to 29.

The science said further rationalisation was required. In 2016, Irish Association of Emergency Medicine consultant Fergal Hickey told a radio interviewer that politicians had failed to see the positive aspects of having centres of excellence.

“What we have is a legacy issue, so we have 29 emergency departments for a population of 4.7m, which is far too many. Many of those departments don’t meet the criteria for what would be described as an [emergency department] in 2016 and one of the difficulties some of them have is that they don’t have the staffing resource which is required.”

So it went in an election year. The next election year, 2020, the same drum was being beaten by the same medics trying to achieve better health outcomes.

Emergency consultant Conor Deasy was on Newstalk radio soon after the election, making the case for rationalisation of trauma centres.

“The solution is a one-stop shop, a single site that has all the specialities on site for those patients that are severely injured,” he said. “We know from international experience that if we do that we will reduce the number of lives lost and the extent of injuries sustained.”

The one discipline where the science beat the politics in health over the last few decades was cancer care. Centres of excellence were established despite major political pushback in some parts of the country.

Driving the project was an outsider, Professor Tom Keane, who came home from Canada to do the job. The then health minister Mary Harney backed him in a rare case of facing down all vested interests for the greater good. The system has saved countless lives and much pain.

Apart from that lacuna, most attempts at genuine, transformative reform have withered on the vine of expediency. In each case, politically, the reform was considered not worth the price to be paid.

This brings us all the way up to today and the current plan de jour, Sláintecare, designed to tackle one of the root problems — the two-tiered system. Much is made of the fact that it has cross-party support but with each passing day, as reality impinges on its stated vision, it seems to be inching closer to the graveyard of such plans. Tom Keane and others of a like mind have washed their hands of it and Stephen Donnelly, the health minister, appears hapless.

As for an alternative approach from a different government, what about the current opposition? Can they go where others have got bogged down?

On Wednesday, Mr Cullinane gave a press briefing on how he sees things. He demonstrated that he has a serious grasp of the portfolio. He is brimming with ideas and, over the course of half an hour, he repeatedly referenced the “energy” that is required to drive reform. If you hadn’t been around for the last couple of decades, you might think he is exactly what the health service needs.

Unfortunately, he neglected to address the elephant in the room. His analysis was heavy with what successive governments have done wrong or failed to do, never once referencing the reasons why change was nearly always stifled.

In Mr Cullinane’s vision, there is no resistance to reform. He said hospital managers would have to be accountable, but he believes many will welcome it. Apart from that, it was a question of who in their right mind would even want to resist what he was proposing.

Mr Cullinane has the capacity to be as good as any who have gone before him, but many of those were also full of beans when sitting on the opposition benches. 

The reality is that fixing the health service will require a lot more than energy and ideas. 

It needs somebody to face down or carry along all the vested interests, from the top to bottom within the service, in the political forum, and among the businesses that thrive in the current set-up.

It’s long past the time when those who believe they will be discommoded or disadvantaged by change set the agenda. Without addressing that, Sláintecare becomes another Hanley report, the musical chairs between government and opposition parties continues, and everybody keeps saying aren’t things just shocking.