Bad situations made worse

Denis Doherty
Denis Doherty

Managing complexity is, by definition, very difficult. Many individual cases are complex which is why specialisation and team working have developed to the extent they have. High performing teams, made up of high performing individuals are greatly valued. Healthcare systems have to cater for a level of complexity as pronounced as in any other service or industry but political debate and behavior often fails to appreciate that. In fact, politicians have a knack of making bad situations worse, writes Denis Doherty.

In a conversation, on radio at the height of the debate on the Hepatitis C disaster, someone suggested that things were so bad at that point they couldn’t get any worse. Someone else disagreed and suggested that as long as politicians are involved, they can get worse. Within days, Michael Noonan, one of our most astute politicians, in an unscripted remark, made the situation much worse by suggesting that the media had deliberately focused on the case of the then terminally ill Mrs. Bridget Mc Cole for the purpose of fuelling the controversy. His remark caused great offence, not only to the women affected but also to the public generally.

Fast forward to the cervical screening disaster. Politicians deserve great credit for appointing Dr. Gabriel Scally to carry out a review of what the contributory factors were. Pity was that a number of Dáil committees decided to involve themselves immediately in public hearings on the controversy. That had the effect of consuming scarce staff resources that could be better deployed assisting Dr. Scally in doing his work. Dr. Scally is a highly respected, vastly experienced doctor who has devoted his career to managing the health of populations rather than individual patients. Evidence is his stock in trade and his work in relation to the cervical screening disaster here is a great example of how a highly complex issue can be dealt with speedily, professionally and to the satisfaction of all the stakeholders involved. A good example of how a complex brief can be well managed.

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the major failing here was that the women who received false negative results were not notified immediately when questions arose in relation to the accuracy of the results they received.

It is generally accepted that the cervical screening programme saves lives and that audit is a best practice component of it. Screening programmes produce false negatives and false positives. Audits assist in producing evidence to enable quality standards to be met and maintained. Based on what is known so far, the major failing here was that the women who received false negative results were not notified immediately when questions arose in relation to the accuracy of the results they received.

The offer of repeat tests to all women who sought them was a well-intended political gesture. It was not evidence based and did not anticipate that the laboratories were not equipped to deal with the volume involved and would cause unacceptable delays in obtaining results. It did not anticipate either that more medically justified tests involving other women would be delayed. A complex issue was compounded by that gesture.

Angela Kerins, the chief executive of a private company that receives part of its funding from services it provides on behalf of public bodies, was, she believed, harshly treated by the Public Accounts Committee and had the courage to pursue her grievance in the High Court and in the Supreme Court where she was vindicated. The role of the Public Accounts Committee (PAC) is a very important one; it conducts its business in public and, therefore, ought to be aware that others with accountability responsibilities may judge the standards it sets as acceptable. Angela Kerins, who attended in a voluntary capacity, was subjected to a form of verbal public punishment beating, and no one shouted STOP. I would not be surprised if even members of the PAC experience difficulty in fully comprehending the complexities of our healthcare system. There are public, private, public/voluntary, voluntary as well as many other for profit and not for profit providers involved. Is it any wonder that many users experience the system as fragmented, disjointed and incomprehensible?

There are many civic-minded citizens who volunteer their time and expertise, on a voluntary basis or for a modest fee, in the interest of the public good. Their generosity needs to be reciprocated if that important resource is to be maintained. In the early days of the National Children’s Hospital controversy and only weeks after a Consultants Report had been commissioned, the Minister threatened that, if necessary, heads would roll. Next day the Chair of the
National Paediatric Hospital Development Board resigned. Is there anyone better suited or more experienced to chair that committee than the man who resigned? I doubt it. Will the Minister’s threat that heads may roll make it more difficult to recruit the best people to serve on high profile committees? I expect it will.

Will the Minister’s threat that heads may roll make it more difficult to recruit the best people to serve on high profile committees? I expect it will.

For years now, politicians of all political persuasions, have been promising us a ‘world class’ or ‘state of the art’ children’s hospital. They have not, however, defined those terms or how much such a hospital might cost. Is it just possible that the projected cost of the specification for the new hospital, shoehorned into a restricted site in a city centre location is what it costs nowadays to build and commission such a hospital in its current location? The governance and management arrangements put in place to deliver the project were always more suited to obfuscating than to illuminating matters and are ill suited to delivering a large complex project successfully.

The review group on the future relationship between the State and the voluntary healthcare sector recommended widespread reforms, including a radical new funding arrangement. If a report in The Irish Times is accurate, reaction to the recommendations has not been positive. It seems that cost implications are an issue. Particularly worrying, though, is the claim that a number of Ministers believe the findings are very close to the arguments put forward by voluntary organisations. Well, tough: considered advice deserves a considered response.

Catherine Day, the former Secretary General of the European Commission, chaired the review group and her colleagues were well qualified and well suited to undertake the task involved. If their advice meets with the same fate as the excellent Fitzgerald Report of 1968 and the many other fine reports that have been shelved in the fifty years since, the message will remain that the valuable contributions of civic-minded experts are not valued in our system and complex issues will continue to be dealt with in the inadequate way they have always been dealt with.