Leadership Crisis In Irish Health Service

A crisis in leadership exists at all levels in the Irish health service and there has been a lack of support for leadership development, according to “Towards 2026,” a major report on the future direction of Irish healthcare. Maureen Browne reports.

Maureen Browne
Maureen Browne

The report is based on the deliberations of a policy forum established in 2016 by the Royal College of Physicians of Ireland to provide an opportunity for open dialogue between over 100 healthcare stakeholders on the future direction of hospital care in Ireland.

It said that only strong leadership at local, regional, national and institutional levels could overcome the lack of trust in the system and bring about the kind of change needed to return the health system to its core purpose.

Only strong leadership at local, regional, national and institutional levels could overcome the lack of trust in the system and bring about the kind of change needed to return the health system to its core purpose.

“It must be recognised that there is a crisis in leadership at all levels, and that there has been a lack of support for leadership development. Clinical leadership roles and managerial leadership capability should be developed and supported at all levels in the system.”

It said major, sustained emphasis was needed on strengthening and supporting the people who delivered care, and on rebuilding trust and confidence among the workforce. Successful organisations recognised the importance of the people who worked for them. They tried to recruit the best, ensure they were enabled to perform to their best, were involved appropriately in decision-making, were trusted and are provided with development opportunities.

Chaired by Dr. Tom Keane, former Director of the National Cancer Control Programme, the report said service delivery should be oriented around the service itself rather than buildings and institutions or legacy arrangements.

It recommended ‘Hospitals Without Walls,’ where many services delivered in hospitals can and should be delivered in the community, with greater collaboration across hospital, primary care and community care settings.

Strengthening capacity in primary and community care would be crucial to achieve this. There should be less focus on the ‘place’ and more on the ‘service.’

It recommended ‘Hospitals Without Walls’, where many services delivered in hospitals can and should be delivered in the community, with greater collaboration across hospital, primary care and community care settings.

The report also recommended that the future health system must put people and patients at its centre in a meaningful way. This meant listening to the patient voice in the planning, design and implementation of services, supporting open and honest public debate on how services were provided and building a sense of partnership between the people who used services and those who provided them.

“It also means understanding population need and the needs of groups with specific vulnerabilities, and designing services to respond to that need. In the coming years this will mean a particular focus on the needs of an increasing population of older people. We must champion the fundamental principle that the healthcare system is owned by the patient and is accountable to the people it serves.”

“Unless action is taken to keep people well, our health system will be overwhelmed by the rise in long-term diseases, such as diabetes. There must be sustained cross-governmental and cross-societal commitment to reduce ill-health through addressing lifestyle trends and inequalities in health outcomes.”

There is a pressing need to redefine the purpose, role and functioning of hospitals and hospital care in the context of a modern healthcare system.

Towards 2020 recommendations included:

Funding – It urged public dialogue on funding and expectations.   Clarity was needed on what could reasonably be expected from the health service, what funding was to be allocated to meet those expectations and how decisions were made to benefit the greatest number of people in a fair and transparent way. “Fundamentally, we must support the principle that people should be able to access healthcare on the basis of clinical need, not ability to pay. Central to this debate will be the issue of what society is prepared to invest in its health service.”

Using data to plan – Healthcare policies, strategies and plans should use research evidence and relevant data to make clear connections between population needs assessment and frontline planning decisions. Of crucial importance was the alignment of capacity with demand through the use of data and evidence. Much of the current visible dysfunction in the system was a result of demand grossly exceeding capacity.

Joined up care – Care pathways should be built around the needs of the patient, not the system. We needed to provide care that was joined up from the patient perspective, through the design and implementation of patient-centred, clinically led, evidence-informed integrated models of care. “Patient outcome and safety measures, costing and funding models, workforce plans and data and system requirements must all be built into these integrated models of care. Funding must be allocated to facilitate and incentivise joined up care, and to avoid fragmented care.

Building for accountability – A governance system that applied at every level, from service delivery upwards, and was grounded in the principle that the healthcare system was owned by and accountable to the people was needed. This required clearly identified responsibility, authority and accountability at all levels of the health service from ward level right up to the Department of Health.

e-Health now – The individual health identifier and electronic health record must be implemented. The advent of the eHealth Strategy provided an opportunity to adopt a long-term strategy to underpin joined-up care across community, primary care, acute hospitals, and mental health, and to simultaneously enable effective population needs analysis, planning, outcome measurement, and performance accountability at local and national levels.

Shared vision and political consensus – A shared vision and long-term strategic plan with cross party political support was essential. Frequent changes in direction were fundamentally destabilising and undermining for the health service. Crucially, it must be recognised that to have a meaningful impact, there must be sustained political commitment to long-term policies and strategies. Cross-party political consensus and longer-term collaborative planning were necessary to support a commitment that spanned multiple government terms and composition.

Towards 2026 said that its recommendations represented an enormous challenge. “Failure to successfully implement change had been a recurrent and debilitating feature of the health service for many years. There must be significant, targeted and sustained investment into making these changes happen. This will require a high level expert group that reports to the Oireachtas on progress and that has the mandate and authority to hold all parts of the system to account for making the change happen. Change will not happen without a plan. Neither will it happen without determined and consistent leadership, from the highest level of government.”

A healthcare system in crisis

“Despite two major reports recommending radical and rational reorganisation of Irish hospitals (the 1968 Fitzgerald report and the 2003 Hanly report), and many other policy and strategic reports, the location, structure and services of hospitals in Ireland today still reflect a largely organic and unplanned evolution, although some progress has been made in rationalising services such as cancer and emergency

interventional cardiology. Despite the fact that medical care and therapies have changed radically in recent years, the structures to deliver these modern therapies has altered little. Joined-up healthcare in this context is not possible. In fact, we have by default designed a system where disjointed, fragmented care is inevitable and where reactive, crisis management has become the norm.

“The public healthcare system in Ireland is in a critical state. Excessively long waiting lists, recurrent and worsening trolley waits in emergency departments and ongoing problems in recruiting core medical and nursing staff paint a picture of a health service in deep crisis. Despite positive health outcomes such as a five-year increase in life expectancy in the last 20 years, and the improvement in outcomes for patients with cancer, it is clear that Irish hospitals are charged with what appears to be an impossible task; the demand for services exceeds capacity to deliver.

“Concern exists that much of this demand may relate to the extent to which patients are referred into secondary and tertiary care with problems that would be better resolved in the primary and community care setting, or spend protracted periods in hospitals after they are fit for discharge. With known demographic trends indicating continued growth in demand, hospital services as currently structured simply cannot deliver appropriate care without radical change.

“Many of the solutions to the problems of the hospital lie beyond the hospital itself, and it is clear that building capacity and capability within the primary and community setting is of the utmost importance.

“There is a pressing need to redefine the purpose, role and functioning of hospitals and hospital care in the context of a modern healthcare system, while learning from the proposals, and barriers to their implementation, identified by previous reports. Notwithstanding the many major problems facing the Irish health service, there is an opportunity to radically improve the patient experience and outcomes in Irish hospitals and to define their future role in a cohesive Irish health service. While the focus of this Towards 2026 initiative is primarily the hospital, it is clearly understood that the hospital can only function as an integrated component of the wider healthcare system. Many of the solutions to the problems of the hospital lie beyond the hospital itself, and it is clear that building capacity and capability within the primary and community setting is of the utmost importance.”