Hitting the target and missing the point

It is critical that health policy strategists and economists ‘think hard and argue hard’ to devise evidence based plans that will enable the delivery of safe quality care to the people of Ireland, writes Dr. Mary Doolan.

Mary Doolan
Dr. Mary Doolan

The health service in Ireland continues to experience unprecedented challenges in providing quality care to the people who need it. Lack of resources and budgetary restrictions have changed the organisation’s rhetoric from ‘world class health service,’ ‘centres of excellence’ and ‘jewel in the crown’ to ‘moratorium,’ ‘equalisation of resources,’ ‘debacles,’ and ‘failures’ (Department of Health 2014, Health Information and Quality Authority 2013). The Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013) illustrates the consequences of systems failure that resulted in a failure to see things from the patient’s perspective with the core purpose of healthcare services overlooked. This Inquiry (Francis 2013) provides stark evidence of many different examples of leaders, managers, regulators and others who failed to prioritise the interests and needs of patients. Although very few, if any, of the individuals involved deliberately or consciously acted this way, the pressures of their work and circumstances led to patient suffering, harm and detriment through the inadequacies of the careprovided (Francis 2013: 1370). There was lack of appreciation of unintended consequences for patients from implementing policies, for instance, in relation to achievement of targets (Francis 2013: 1361).

Any health system which focuses on value for money is deemed to ‘hit the target and miss the point.’

The recent publication of the Public Service Stability Agreement 2013-2016- Haddington Road Agreement – Stage 3 Implementation Plan (Health Service Executive (HSE) 2014) raises serious concerns for the delivery of safe quality care in Ireland. This plan focuses on targets, savings and ‘straight line reductions’ (HSE 2014). Whilst these cost cutting measures are unquestionable economic targets, it is imperative that service providers consider fiscal adjustments in the context of available and emerging evidence from neighbouring jurisdictions. Learning from what went wrong in the delivery of safe quality care in the Mid-Staffordshire Trust is clearly embedded in the formulation of current health policy in the United Kingdom (Department of Health 2013, National Quality Board 2013, Keogh 2013, Berwick 2013); yet, policy makers in Ireland seem destined to dismiss established evidence.

All members of the multidisciplinary team have an equally critical role in the delivery of effective patient care including nurses, midwives and healthcare assistants. The valuable contribution of health care assistants in the delivery of quality care is well documented (Cavendish 2013, Talty 2013). Nonetheless, high quality patient care is directly linked to a higher proportion of registered nurses in the nursing staff establishment (National Institute of Clinical Excellence 2014, Department of Health 2013). In fact, Aiken et al (2014) as part of the RN4CAST project which involves twelve European countries including Ireland, consider nurse staffing cuts to save money as potentially adversely affecting patient outcomes. Specifically, the RN4CAST study, the largest and most rigorous investigation of nursing and hospital outcomes in Europe, suggests that a safe level of hospital nurse staffing might help to reduce surgical mortality (Aiken et al 2014). Likewise, failure to ensure adequate nurse staffing is a key finding in the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013). Furthermore, there is a significant relationship between registered nurses staffing levels and the prevalence of care left undone, which is a potential indicator of poor quality care (Ball et al 2013).

Recent pay reductions under HRA have meant there is very little difference in pay between a newly appointed mental health nurse (€27,843 – €38,479) on the bottom of the scale compared to a HCA (€25,578-€29,616). However, as nurses progress through the increments, by the time a nurse has reached their 3rd increment (€30,336), they have surpassed the HCA who is on the maximum of the scale; therefore there is value in pursuing the skills mix model, both from a fiscal perspective as well as a nursing service delivery model (HSE 2014: 82).

Blind adherence to targets or finance must never again be allowed to come before quality of care.

When things go wrong in the Irish health service, service providers must account and apologise for breaches in the delivery of safe care. Any health system which focuses on value for money is deemed to ‘hit the target and miss the point’ (Department of Health 2013) in relation to quality safe patient care.

High quality care is clinically effective, safe and delivers as positive an experience as possible for patients (Keogh 2013). ‘Regular replacement of staff in acute hospital services by graduate nurses, replacement of essential vacant posts with graduate nurses and interns in community, and ‘skill mix of 40:60 nursing: healthcare assistant in public residential care services’ (HSE 2014) warrant serious further discussions in terms of emerging evidence from neighbouring jurisdictions.

The health service in Ireland is already dogged with criticism, with the media consistently publishing and reporting failures and short falls in the service. Current fiscal policy as stipulated in the Public Service Stability Agreement 2013-2016- Haddington Road Agreement – Stage 3 Implementation Plan (HSE 2014) may have significant negative effects on the delivery of safe care to the Irish population across all sectors. Robust systems must be established as a matter of urgency to ensure that nursing, midwifery and care staffing capacity and capability is sufficient (National Quality Board 2013), prior to any consideration of ‘straight line reductions’ and ‘enhanced skill mix opportunities’ (HSE 2014).

Blind adherence to targets or finance must never again be allowed to come before quality of care (Department of Health (UK) 2013:10). The Irish health service is at real risk of ‘hitting the target but missing the point’; hence, it is critical that health policy strategists and economists ‘think hard and argue hard’ to devise evidence based plans that will enable the delivery of safe quality care to the people of Ireland.

Dr. Mary Doolan
Nurse Tutor, Regional Centre of Nursing & Midwifery Education Midland Regional Hospital, Tullamore, Co. Offaly