Merger of WIT and IT Carlow – risks and hard questions

In an opinion piece published in the Irish Times yesterday I responded to a report from Michael Kelly on the ‘Engagement and Consultation Process on a Technological University for the South-East‘. Today I’m going to expand on my earlier piece, and explore some of the other issues involved in setting up a Technological University in the South-East. I’m indebted to a number of people, from Waterford, Carlow, and further afield,  who contacted me about this over the last few days.

Higher education

Proposals to build a university in the South-East go back for over thirty years. The logic of doing this is hard to dispute. There’s good evidence that universities contribute to economic growth, in many different ways, and the potential benefits of setting up a university in the region have been well described in many sources, including the Kelly report . Waterford IT itself is a successful IT,  with good academic outcomes, and a very respectable track record in research and development. It’s the obvious keystone for a university in the region. IT Carlow is also a successful IT, but one with a radically different profile, and a strong focus on training.

One of the difficulties in talking about TU’s is the risk of running down the IT’s. To be clear, a successful education system has to provide access to a broad range of educational opportunities for everyone. This includes a working further education system, as well as higher education. Traditionally higher education in Ireland was divided into two groups, the Regional Technical Colleges, later the IT’s, who did apprenticeships, certificates, and diplomas, and the universities, who did degrees. For many years the IT’s awarded degrees only in partnership with universities, but more recently they have been allowed to award degrees themselves.

Irish parents have a strong preference for degrees. This has led to big increases in the number of kids doing degrees in the ITs and a fall in those doing certificates and diplomas. Arguably, this has weakened the whole system. It has certainly become harder to start with a certificate, and work up the system to a higher degree. It also leads to a moderately high dropout rate from first year degree course in the IT’s, as people who might, perhaps, have been better advised to start with a certificate, find they can’t manage a degree. I suspect that a fair of these would manage a degree later on, if they wanted one, but at age 18, many people do not have the maturity to manage a degree course.

The key point is that IT’s, technological universities, and ordinary universities are all doing something important, but they are also meant to be doing something different.

Mergers, risks, and management

Mergers are dangerous. Many mergers fail, and mergers can destroy large, and apparently successful organizations. Failed mergers destroy value, because they consume management and staff time, which could have done something more useful; and because the new body can be seriously, or even fatally, weakened by the merger process. It is perfectly possible to merge two good profitable companies and end up with one bad, loss-making, company. Of course, public sector bodies don’t usually exist to make a profit, although IT’s must balance their budgets, but the services they give can be badly damaged. The evidence is that, to succeed, a merger needs a clear, agreed, goal, and that both partners need to trust and respect each other. They also need to know each other very well (i.e. to have done a proper due diligence).

Red flags

Given the risks of a merger, reading Michael Kelly’s report should bring any properly designed civil servant out in a cold sweat. The process of merging WIT and IT Carlow has not gone smoothly, to say the least. WIT, an organisation that has had its own troubles over the last few years, walked away from merger talks in October 2014. At that point only the first stage of a four stage process leading to a technological university had been completed.

Someone in WIT pointed out to me that, at least until recently, the proposal for university status is not driven primarily by WIT, but by the city and local chamber of commerce. This person also felt that, for most staff members in WIT, the whole merger process was not very salient – ‘IT Carlow featured far too rarely in discussions of the future of the Institute’. I suspect that many staff in WIT feel the same way.

Kelly’s report, based on work with senior managers, the governing authorities, and others, includes many descriptions of how WIT and IT Carlow view each other. Phrases like “there is little evidence of previous formal collaboration”, “many instances of negative commentary, formal and informal, have been unhelpful and hurtful”, “need to build mutual trust and respect as the foundation of equality of esteem”, “doubts about the real level of commitment to TUSE” all occur. This is what has been published – what has not been published ought to frighten everyone.

This is not the basis for a viable long-term relationship, nor is it the basis for a successful merger over the next few years. WIT and ITC have also recently produced two separate visions for a technological university in the South East, which should also cause concern. Kelly shows that there are many common elements in the two visions, and I think he is right, but this is not a good place to start from.

One missing piece is mutual due diligence. Merger’s require transparency, and trust. They also require a lot of work to make sure that everyone on both sides knows where they stand. This is due diligence. Neither IT has completed this yet. In addition a key part of the TU process is preparing a detailed report on the performance of the two IT’s – this has yet to be completed for either. Again, this suggests that neither IT is yet ready to move to a merger. As Kelly observes, no IT will agree to a merger without some assurance that they will be able to form a TU. At the moment, WIT is much closer to meeting the TU criteria, than IT Carlow. The merged entity will be further from meeting the TU criteria than WIT is right now.

Managing risks

The risks of proceeding with the merge are not well described in the report. There is no more than a brief mention of the need for further resources, and a little further detail on the importance of achieving a common vision. It is proposed to finish in three years or less, which I believe to be unrealistic. The Dublin technological university process, which Kelly leads, and which has full support from all the ITs involved, has taken longer than this already.

I see further major risks, which need to be dealt with. Neither IT is ready. They dislike each other, and do not trust each other. Much work is needed to bring the two organisations on board, and it may not be possible to do so. It is regrettable this has happened, but it would be worse to pretend it has not, or that it does not matter

The price of moving ahead will be high. The direct costs of the merger will be, I think, a minimum of €4 million. There is also a big opportunity cost. Neither IT will have management time to develop themselves during the merger. They may not have the time, energy and resources to manage themselves properly.

There is a real risk of the merger dragging on for several years, with acrimony, suspicion and misery, and ultimately failing. This would do serious damage to the reputation of both ITs and the wider sector.

Conclusion

There are significant risks to proceeding. As far as I can see, these have not yet been properly considered, and no mitigation is proposed. If this is to go ahead, and to have any chance of success, I see no option but to start with a mediation process. This will mean further delay, but I feel it is necessary. Both partners are badly hurt, something which comes across very clearly in their responses to the report.

An alternative is to review the merger. It’s not obvious to me that the merger is either necessary, or helpful. There may be a case for a merger, but I think it needs to be reviewed and justified first.

Unless the work is done now to repair the hurt, to restore a sense of trust, and to establish real mutual esteem, any attempted merger will be a shotgun wedding, with results better imagined than experienced.

I am a member of the Higher Education Authority, but I write here in a personal capacity, and I do not speak on behalf of the HEA.

Children’s rights and same-sex marriage

Children have the right to be parented. There is a duty on society, and the state, to support both parents, and children, in meeting this need. Everyday experience, and abundant scientific evidence, tell us of the importance and significance of the parent in the life of every child.

Parenting means that one, or more, adults makes the raising of that child a primary focus of their life for many years. The way this is done changes over time – the experience of parenting today is not the same as thirty years ago – but the task remains. This is a challenging commitment, but it is a commitment to which many people rise very successfully.

Children are effectively parented both by married and unmarried couples, be they of the same gender, or mixed genders. They are also effectively parented by single people of either gender, some who have always been single, and others who are separated, widowed or divorced. All kinds of people can make ‘good-enough parents’, and can provide happy, stable, and secure childhoods, with good outcomes, for their children.

There has always been a fear in our society of the consequences of changing parenting. In the past it argued that working women could not raise their children adequately, and that only if a mother stayed at home could the children hope for a happy, stable and secure childhood. Few would argue that today. Our understanding of the what makes an effective family, and what is needed for ‘good-enough parenting’, has changed. The fear of same-sex marriage is as confused now, as the fear of working mothers forty years ago.

Most children are produced by the usual method, good old-fashioned heterosexual sex. A minority, but an increasing minority, are produced with aid from one form or another of assisted human reproduction. These children come from all sorts of families, single, married, straight, gay or lesbian, and they have the same needs as any other child, and ought to have the same rights. The only difference for same-sex couples is that they do not have the opportunity to conceive a child themselves – some external assistance is necessary.

Marriage matters, because it is a sign of social recognition of the intent of two people to seek a serious, stable, faithful, and long-term relationship. Raising children is hard. Many single people do it very well, but it is still hard. How hard is shown by the significant discrepancy between the average outcomes for children raised by one parent, and those raised by two. The reasons for this are complex, and include poverty, education and instability, but the effect is real.

Marriage is a public demonstration of a long-term committed bond, between two people. Couples have a lot of different reasons for getting married, for example, to show love, for mutual support, and to make a public acknowledgement of their commitment. One key reason is to help each other to raise children. States involve themselves in marriage for a number of reasons too. These include the regulation and recording of a central human relationship, the proper regulation of property, taxes, and housing, and to identify and regulate parenting, and parental responsibility. The raising of children also matters to the State, both because children are the future of the state, and also because it often has to pick up the pieces if it all goes badly wrong.

Stability matters for raising children. Marriage is one way, thought not the only way, of helping a couple to establish and maintain a long-term stable relationship. Few doubt that marriage is good for many of the children of mixed-sex couples. The children of same-sex couples ought to have the same rights as the children of any other couple, to grow up in a family based on marriage. That’s a reason why I’m voting ‘Yes’ next Friday.

Portaloise – the HIQA report

Mother and Child - Photo by Aaron Kraus CC BY-NC-SA 2.0

Mother and Child – Photo by Aaron Kraus (CC BY-NC-SA 2.0)

The widely leaked HIQA report into Portaloise Hospital is out now. The various pieces can be downloaded from www.hiqa.ie

The context is well known, serious failing in maternity care in Portlaoise, identified by a great team of reporters from the RTE programme PrimeTime investigates, and detailed in a very clear, and very explicit,  report from Tony Holohan, the CMO. That report concluded :-

” that clear failures in the management of risk and patient safety occurred in Portlaoise Hospital Maternity Service. These failures were at a number of levels, both local and national. One of the overall conclusions of the Report is that Portlaoise Hospital Maternity Service cannot be regarded as safe and sustainable within its current governance arrangements.”

A new management team was to be put into Portaloise maternity services “with immediate effect” and oversee an integration of those services with the Coombe Hospital. The report was published on February 24th 2014. HIQA’s report, published May 8th 2015, notes that these crucial arrangements were still not in place. A memorandum of understanding (MoU) was finally signed in March 2015, but no action had yet been taken. It appears that ‘immediate’ has an idiosyncratic meaning in the Irish heath services.

What does it say? In summary – everyone got it wrong. Portlaoise itself was mismanaged, and it was seriously under-resourced for the tasks it was trying to perform. The report identifies very serious and very urgent problems in obstetric, surgical, medical, diagnostic imaging, and A/E services in Portlaoise. These problems need to be addressed. The management and culture of Portlaoise was weak, with poor systems for quality assessment. Organizational arrangements were complex, and unclear.  There was poor communication between the local and regional management. The central management seem not to have been aware of the seriousness and the urgency problems in Portlaoise. They should have been, as a number of previous reports had raised red flags about Portlaoise. To quote :-

“There were many reasons why the HSE should have maintained very close oversight of the quality and safety of services at Portlaoise Hospital. These reasons included local and national HSE inquiries and clinical reviews into patient-safety incidents, significant service failures, statutory investigations of hospital services, and resultant publication of findings and recommendations. However, there was no evidence that the HSE nationally was proactively exercising meaningful oversight of the hospital and the inherent risks there.” (Executive summary p 6.).

What can we learn from this? There will, no doubt, be the usual calls to execute a few scapegoats. However, I believe that the problems lie much deeper than a few, or even a large number of, inadequate individuals. I am fairly confident that even if we sacked the whole HSE senior management team, the regional managers, and the local managers, this would not address the deeper problems, and we would find ourselves back where we started in a few years.

There is a deep culture of non-accountability in the Irish health services, and in many parts of the Irish public services too. This leads to a failure, and often a refusal, to manage projects effectively. It also means that proper information systems are given a very low priority. The worst effect of all this is drift.

Very little happened in Portlaoise after the RTE programme and the CMO’s report. A director of midwifery has been appointed, and has had a big impact on maternity services. The other problems have been let drift gently on. The most blatant of these is the failure to actually engage with the new management structure for maternity services, headed up by the Coombe. The fact that it took 13 months to set up an MoU, and that after 16 months it has still not been activated speaks for itself. None of the hard decisions about surgical services and A/E services have been made. It is still not clear what role Portlaoise is expected to play in the future of the Irish health services.

Had Ireland had even remotely adequate information systems the problems at Portlaoise would have been identified much faster, and lives would probably have been saved. However, even with our existing systems, had the management up and down the organization taken the warning signs seriously, all of this could have been prevented. None of us escapes without blame and responsibility. The failures in Portlaoise are symptoms of a much wider failure across the health services, and I think, the wider Irish public services.

Child outcomes in families of same-sex couples – some evidence

Marriage equality demo in Paris in 2013 - Wikimedia commons

I have looked at recent evidence on the outcomes for children raised by same-sex parents. The short version is that there is no evidence for worse outcomes in children raised by same-sex couples. My detailed review of these studies, with references, is elsewhere on this website.

Specifically a large number of studies have shown, quite consistently, that there are no major differences between children raised by same-sex couples, and those raised by comparable heterosexual couples. As in any area of research, the studies vary in quality, and in design. Almost all are small studies. They are done on more or less selected samples of parents. There are flaws in every single study reviewed (however there are flaws in every single study ever done, on any topic!). There are hardly any studies on families headed by gay men.

The better studies have compared selected lesbian couples with similarly selected heterosexual couples. There are at least four well designed studies, all of which I have reviewed in detail, that have shown no material difference. There are also a large number of weaker studies, of which I have reviewed the more recent studies only, that show the same thing. Several good quality reviews of this and older evidence support my conclusions.

There are studies, three to be exact, that have shown different results. Each has shown worse outcomes for children raised by same-sex couples. Each of these studies has critical flaws which, in my judgement, make them unreliable. I describe these in my more detailed review.

What are my qualifications to do this? I’m not a lawyer, nor a social worker, nor a specialist researcher on this topic. What I am is an epidemiologist, with an original training in paediatrics, and a track record in child health research. I have a lot of experience in study design, data analysis, and the critical reading of scientific literature. My cv is elsewhere on this website. I have worked on the interface between evidence and policy, and evidence and practise, for many years.

The evidence is not, and never will be, perfect. The evidence that exists, which is of reasonable quality, and reasonable quantity, is quite consistent. All the studies, without crippling flaws in design, show that lesbian women are perfectly capable of being ‘good enough parents’. This is the criterion we use for everyone else, so there is no evidence supporting the prejudice expressed by many opponents of the marriage equality referendum. For gay men, there is much less evidence, but the little that exists is consistent with that for lesbian parents. There is no reason to oppose marriage equality for the sake of the children!

DOCTRID conference – selected notes

I’m just back from the fourth DOCTRID conference  in Belfast. DOCTRID is the research arm of the Daughters of Charity. It funds and oversees research in the field of ID and autism by bringing experts from medicine, social science, education, computer science and engineering together. DOCTRID was established in 2010 as an international, interdisciplinary coalition of universities, service providers dedicated to improving the quality of life for people with Intellectual Disabilities (ID) and autism through research and technology.

Queen’s looked lovely in springtime, as always, and we had two lovely bright sunny days. This was a great background for two days of serious work. The aim of the conference was to create a better understanding between researchers, caregivers, healthcare providers and people with ID and ASD to bring practical changes to people’s lives, in particular through the use of Assistive Technology.

The challenges posed by living with intellectual disability and/or autism are very complex, and affect every area of the life of the affected person, and their families. Solutions must be equally broad, and need to be centered on the needs of the person.  DOCTRID IV aims to provide solutions to improve the lives of people with intellectual disability and autism. There are four themes in the conference, and for each, there was a presentation, and a workshop. The themes were :-

  • Quality of Life and Social Inclusion
  • Gaps and innovations in service delivery
  • Prevention and Epidemiology
  • Future and Assistive Technologies

DOCTRID participants talked about how research in technological, behavioural and social sciences could meet the needs of people with ID and ASD, caregivers and practitioners to improve communication, independence and access to education, and to inform policy an implementation around more effective service provision.

I was asked to talk as a respondent, with Jean Kerver from the US, to a talk on neuro-disability research by Bernard Dan, who is a pediatric neurologist from Brussels. He spoke very powerfully about the importance of tying together clinical observation, the experience of the patient and their family, with genetics, epidemiology, and animal models of disease. Jean added in the ideas of the importance of nutrition, and gave examples from her work on folic acid and iodine.

I spoke about information. This included information about what was being done, how the money was spent on services, what the outcome of these services was, and how accountable service providers were for service delivery. Too many services, both in the ID sector, and more widely, are run in the interests of the organization, rather than the clients. The second aspect of information was the dearth of evidence for many interventions in the lives of people with ID. For example, I have little doubt that ABA works for many children with ASD. However, there are very few trials of any kind of ABA, and none of these are very convincing. There is a real need for better evidence of the effectiveness of these interventions. The third use of information was a plea to take the voices, views, and interests of the clients much more seriously.

This last idea was inspired by, and ties into, the other presentation that really struck me. Jennifer Clegg is an Associate Professor and Honorary Consultant Clinical Psychologist, Faculty of Medicine & Health Sciences, at the University of Nottingham. Her work is broad, but she spoke at DOCTRID about the moral implications of moving people out from congregated settings.

In our society autonomy and individualism are highly prized. There are other ways of thinking about values, and relationships. These include placing a priority on relations. It is not necessarily the case that every person with intellectual disability wants to live, on their own, or with one or two others, in the wider community. Talking with people with ID, friendship, company, and relationships are (unsurprisingly) important. Any policy for moving people out of institutions needs to respect this, and to respect the needs, wishes and desires of the client, even if these are not to move out. This is not to justify the really poor practices of the past, and the present. There are several institutions providing warehousing for people with disabilities which need to be closed. Many people with ID wish to live independently, and should be accommodated, with services reconfigured as support services for them in community living. However, not every client fits this description, and not every client wants it. Part of autonomy is the right to refuse change offered to you.

Primary care and the new GP contract

The new GP contract  was the subject of much debate and discussion at the IMO AGM over the weekend, and the members have supported it. There are more details of the draft contract on the IMO website, but all seem to be in the members-only section. (As I’m a member I can read them, but I don’t think it appropriate to share more widely). Thecouncil of the other main GP representative body, the  NAGP, met on Sunday, and are reported as having rejected it unanimously. What is going on?

The backstory

The contract comes out of a year of negotiation, led by the new IMO president Ray Walley. This started when the DoH drew up a draft new GP contract, apparently by looking into their hearts, and launched it in early 2014. The various associations said no, quite unanimously, and after some further talks, the IMO and Alex White drew up a framework agreement for negotiations which was published in June 2014. This framework has led to the current draft contract.

The main features are :-

  • Free GP care for all 270,000 children under 6, including two child health checks at ages 2 and 5 (€67m)
  • Free GP care for everyone aged over 70, who does not already receive this (36,000 more people) (€18m)
  • Two modules for chronic disease care (€4.5m), one for diabtetes, and one for asthma (included in the Under 6’s)
  • A new dispute resolution process for dealing with PCRS (these are mostly disagreements about payments)

The total cost (according to the DoH press release) is about €89.5m. These new GP visit cards do not provide for free drugs.

Against

There seem to me to be three main objections, based on reading the media, talking to people, both at the IMO AGM, and elsewhere, and looking at social media:-

It’s unfair to give free GP care to all children under 6, while leaving children over 6 who have health problems, paying for GP care.

If we look at fairness, then the argument that this is unfair has some force. However, there is no easy way to grant access to free GP care fairly. The recent report from Frank Keane and his colleagues on ‘Medical Need for Medical Card Eligibility’ concluded that “In the absence of international objective and reproducible methods of measuring burden of disease and illness, it is neither feasible nor desirable to list conditions in priority order for Medical Card eligibility. A listing approach risks inequity by diagnosis and a further fragmentation of services.” They also suggested that “a priority for the health service should be to use these recommendations as a stepping stone to the implementation of the first phase of the Government’s Primary Care reform programme, providing free GP care for all, with the aim of further ensuring universal access to the full spectrum of Primary Care Services as a matter of course and thereby aligning the health service in Ireland with health systems in other EU Member States”. They argued for a more systemaitc approach, and a more compassionate approach to granitng discretionary medical cards, but not for their general extension to groups defined by diagnosis.

There will be a lot more visits to GPs by parents with small children, so GPs will be swamped, and get paid very little per visit.

The burden of extra visits is much harder to assess. People whom I respect have come to different conclusions about the impact of extra visits, and I do not presume to decide myself. It seems likely that there will be some extra visits, and this reduces the value of the extra capitation fees. This is probably the key business decision for each GP to make. I doubt if it make much sense to continue thinking about general practice in terms of costs per visit. It will be important for practices to come up with novel ways of managing visits from well youg children. There seems to me to be a clear role for practice nurses with an interest in child health and asthma to take on some of this work. In other health services, such as the NHS, such staff are paid for centrally, and this is a model that should be pursued further here. In addition, much closer links between GPs and the community health staff might be a good idea.

HSE will not be able to make it all work, and there will be another adminsitraitve fiasco, and GP’s get to pick up the pieces.

Whether HSE can do the registration is currently a major unknown. PCRS seems to me to be one of the more effecitve pieces of HSE, when it comes to using ICT, and they might be able to do it, if the registration process is simple enough. There is a risk of a mess, but I hope it will not happen.

For

What are the advantages? I see two :-

First moves towards a single tier health service

The Irish healthservices have been crippled for years, by a peculiarly perverse two-tier health system, with payments for primary care, but free access to many hospital services, and two sets of queues, private and public, fast and slow, for the same services. Many people in Ireland do not realise how twisted and perverse this is, because we all grew up with it. It is also rather expensive, unfair, and quite disruptive. A single tier system would, almost certianly, cost less to run.

First moves towards paying GPs for doing integrated care

Most, if not all, GP’s have been providing integrated care for long-term illnesses for many years. Up to now, there has been no real mechanism to pay for it. The asthma and diabetes care payments are a baby step on the road to properly resourcing GP’s to care for people with long-term illness.

My 2c.

Overall, I’m going with my union (I’m a current IMO member, and a former IMO executive member). I do think that this is a good start, and the first instalment of a useful, and very necessary, increase in resources for general practice.. It is only a start, but it is one of the biggest changes at the sharp end of our heath services in some time.

Adoption and same-sex couples – some evidence

In the light of recent discussion on the Child and Family Relationships Bill, and some issues raised by the referendum on marriage equality, I have looked at recent evidence on the outcomes for children adopted by same-sex parents. The short version is that there is no evidence for worse outcomes in children adopted by same-sex couples. My judgement is that there is enough evidence to support equality in adoption for same-sex, and heterosexual couples. I believe that the onus is on those who argue against allowing adoption by same-sex couples, to to produce the evidence to support their case. In a future post I will look at the wider evidence on children raised by same-sex couples.

First, what are my qualifications to do this? I’m not a lawyer, nor a social worker, nor a specialist researcher on this topic. What I am is an epidemiologist, with my original training in paediatrics, and a track record in child health research. I have a lot of experience in study design, and data analysis, and the critical reading of scientific literature. My cv is elsewhere on this website. I am not a lawyer, and will not be commenting on any legal issues in the bill.

The most accessible recent review on the overall topic of children raised by same-sex families, a report for the Williams Institute at UCLA, by Abbie Goldberg and colleagues, can be found here.

Background

There is a detailed explanation of the origins of the bill, with links to the relevant documents on the Children’s Rights Alliance website. I recommend particularly Geoffrey Shannon’s review, which is accessible from that page, or directly here. The CRA summary of the bill is concise, and I fully agree with it –

The Children and Family Relationships Bill represents the most important reform of child and family law for a generation. The proposed legislation seeks to put children at the heart of family law, provide legal clarity around various family types and address discrimination faced by children in non-marital families. It is hoped that it will significantly reduce the number of cases going to court due to the current legal vacuum.

There are a number of areas of the bill that are potentially controversial, although the most complex piece, on surrogacy has been passed back to the Department of Health for further review. As far as I can see from listening to discussions in the media over the last few days, and in particular to the contributions from Mothers and Fathers Matter, one issue is allowing adoption by same sex couples.

In the interests of full disclosure, I should add that I strongly agree that children have a right to identity, and specifically, to know the full details of their biological and social origins. I also feel, very strongly, that children whose parents split up, have a right to maintain contact with both parents. As a result, I strongly support the donor register in the bill, and I oppose anonymous sperm donation, ovum donation, and surrogacy. I respect the views of the people in ‘Mothers and Fathers Matter’, and I am friendly with one of the people involved, my ex-colleague from UCD, Ray Kinsella. I respectfully disagree with them on the issues of marriage equality, and the use of assisted reproduction technologies, and adoption, by same-sex couples.

Evidence

The summary of the evidence can be quite bald. There is no particular evidence that the outcomes of children adopted by same sex couples differ materially from those of children adopted by heterosexual couples.

There does not seem to be a huge amount of recent research on this topic. There is a paper by paper, and study by study summary elsewhere on this site, listing all the papers I have found, so if I’m missing something, please accept my apologies and let me know.

US First child adoption study

This is a series of papers on a set of couples adopting a first child from Abbie Goldberg, JuliAnna Smith and colleagues. These studies recruited a group of parents adopting their first child through adoption agencies, and gay and lesbian NGO’s across the US. To be included in the study, couples had to be adopting their first child, the child had to be under the age of 18 months, and both partners had to be first-time parents. Adoption agencies in the United States were asked to provide study information to clients who had not yet adopted. Both heterosexual and same-sex couples were targeted through adoption agencies to facilitate similarity on geographical location and income.

Couples were interviewed on two occasions, just after completion of their assessment of suitability for adoption (the home study), and three to four months after the placement began. They were asked to complete questionnaires after each of the interviews, and again 12 months after the placement. There were between 120 and 140 couples in the different reports from this study, a little over a third of whom were heterosexual couples, about a third, female same-sex couples, and a little under a third male same-sex couples.

There were no material differences in outcomes for the children, and the experiences of the parents were also very similar between the three groups of families, and were as expected from the existing literature on adoption.

The Los Angeles study

There are two reports from a study of children adopted by 82 families in Los Angeles (60 heterosexual, 15 gay, and 7 lesbian) from Justin Lavner, Jill Waterman and Letitia Peplau, who took part in the UCLA TIES for Adoption service. This was, and is, an add-on service, to routine pre-adoption support, for people adopting ‘high risk’ children from foster care. The parents in this study were recruited between 1996 and 2001. Families were assessed at 2 months, 12 months and 24 months after the placement.

Children showed improvements in behaviour and intellectual ability after adoption. There was no difference between the three groups of families in these outcomes, although the children adopted by the same-sex couples had slightly higher levels of biological and environmental risks prior to adoptive placement.

The high risk adoption study

This was a study of parents, fostering children, with a view to adopting them, through US Child Welfare Systems. 84 people took part, from 42 couples, (17 lesbian, 13 gay, 12 heterosexual), who were interviewed 3–4 months after they were placed with a child whom they intended to adopt. This was a qualitative study.

It is well known that the challenge of fostering a child, with a view to adoption, is considerably greater than that of the more common adoptions. Again, there were few differences between the three sets of couples. All identified issues with the legal system, with social services, and with the child’s relationship with their birth family. For the same-sex couple and added stress was the variable legal recognition for them both as adoptive parents. In some US states only one member of a same-sex couple can legally adopt a child. A second stress was anxiety about the views of the birth parents about a placement with a same-sex couple. Neither of these was raised as an issue by the heterosexual couples.

Interpretation

There is not a huge amount of evidence on the question we are addressing here, outcomes for children adopted by same-sex couples. However, the evidence is very consistent, and is also consistent with the wider body of evidence on adoption. There is no evidence for worse outcomes in children adopted by same-sex couples. It is of course, almost an academic joke, that every paper ends with a call for further research, and some further studies on the outcomes for all children raised by same-sex couples have started recently. As far as I know, there are no new studies specifically looking at the outcomes of children adopted by same-sex couples underway. If you know of some, please let me know and I will edit accordingly.

Is there enough evidence for the Child and Family Relationships Bill to become an Act? Given what these papers show, it is hard to argue that further research is a high priority. There are many pressing social problems, few researchers, and limited budgets. However, for making policy, there is a moral and ethical imperative to make use of the existing evidence, whether it is abundant or scant. My own judgement, and it is a judgement, though I hope an informed judgement, is that there is enough evidence to support equality in adoption for same-sex, and heterosexual couples. I believe that the onus is on those who argue against allowing adoption by same-sex couples, to produce the evidence to support their case.

Primary care – can pharmacists fix it?

The IPU held a seminar today, reported by Paul Cullen in the Irish Times. I wasn’t at it, but I found the report intriguing.

Based on Paul’s report, and the press release on the IPU website, the general proposition was that ‘Pharmacists hold key to reducing pressure in GP’s surgeries’. There were two main points, one that many minor ailments which could be dealt with elsewhere are managed by GPs, and the other that more generic prescribing could save the Irish health system a lot of money. The second is true, but only if we get our act together on generic drug prices, and enforce generic prescribing, as the NHS has done. Incidentally, there is reasonable evidence that pharmacists can make an important contributor to improving the quality and safety of prescribing (e.g. Chisholm-Burns MA, Kim Lee J, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010 Oct;48(10):923–33). What about minor illness and pharmacists?

There is quite a bit of evidence that pharmacists can make a very useful contribution to healthcare. There are two relevant Cochrane reviews, one on the ‘Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns, and one on’Community pharmacy personnel interventions for smoking cessation‘. There are over fifty other reviews, and several hundred studies on various outcomes, diabetes, asthma, mental health, and more. Most of the ones I have skimmed seem to look at the role of pharmacists as part of a larger system of integrated care, or the impact of pharmacists on prescribing. Based on the reviews, and on reading the abstracts of about twenty interesting sounding papers, there is reasopnable evidence that pharmacists can provide effective care to patients.

The key intervention at the conference came from Colin Bradley, the professor of General Practice in UCC. Paul Cullen reports him as saying ‘there were significant financial and other obstacles to be overcome before GPs agreed to the scheme.Family doctors could feel it would “take bread out of their mouths” and needed to be properly resourced to treat chronic diseases’. I think he’s right. Why?

Suppose that it was decided to switch care to pharmacists in the morning. What would happen? Pharmacists are cheaper than GPs, partly because they can subsidize their premises by selling drugs, perfumes, makeup and so on. Pharmacists would skim off some of the simpler end of the GP business, leaving GPs to deal with the more complex cases, and the sicker patients. These are the patients GPs lose money on. In the same way that private hospitals in the US cherry picked the less sick patients to treat leaving public hospitals to deal with the more costly, and less profitable, cases (e.g. Cram P et al. Insurance status of patients admitted to specialty cardiac and competing general hospitals: are accusations of cherry picking justified? Med Care. 2008 May;46(5):467–75), pharmacists would undermine general practice. I also suspect that if anything went awry, the patient would end up back at the GP very quickly.

I’m not arguing that the IPU are wrong. From my perspective we seriously under-use pharmacists. We are beginning to use them more effectively, for example in giving flu shots, but there’s a long way to go. If we are to make full use of community pharmacists, practice nurses, and all the other staff in primary care, we need a new primary care contract, covering GPS, their staff, pharmacists, and others. We need a contract which pays, properly, for managing chronic disease, and which pays, properly, for integrated care.

This will cost. My (really crude) estimate is about one billion euros extra to fully develop primary care. This money could come, mostly, from the current acute hospitals budget, along with many skilled staff, patients, and clinical responsibility. In such a system, community pharmacists could use their full range of skills, not just improving prescribing, and reducing drug errors, but also providing direct patient care, mainly for those chronic disease managed by drugs, such as diabetes, raised cholesterol, asthma, and high blood pressure. This care would be provided as part of a team, in my view a team led by GPs, sharing information, sharing responsibility, and sharing the resources provided.

Could this be done? I think it could. Irish GPs are very innovative, and they continue to do an amazing amount of good care, in a very difficult situation. Irish pharmacists, evidently, want to step up, and meet this challenge too. Will the HSE/DoH join in? I really hope so!

‘On Wednesday We Wear Pirate Hats’ The BT Young Scientist &Technology Exhibition and the state of younger people in Ireland

I was lucky enough to be one of the judges at the BT Young Scientist’s exhibition in Dublin in the first week of January. This gave me two rather different opportunities to see Irish school children. First, I got to meet the people who put in projects. These included the eventual winners, Ian O’Sullivan and Eimear Murphy from Cork, and about forty other people, all aged between 12 and 18, whose group projects, all entered into the Social and Behavioural Sciences section of the exhibition, I got to judge. (Every single project gets judged three times, independently, and those in the running for prizes are reviewed by further judges.)

They were a very impressive group. Even the weakest projects showed effort, enthusiasm, and a lot of work. The good ones would have been very acceptable from good university undergraduates. The projects that won the prizes in our section, were better again. The overall winners, after only a years work, were at the standard I’d expect from a good MSc, and their work was immediately publishable. This is an astonishing accomplishment. All the students who entered, their teachers and their families, deserve great credit.

The topics they presented, however, show a slightly darker side to Irish life. ‘Alcohol consumption – does the apple fall far from the tree’ from the overall winners asked a simple question – How do parental attitudes to alcohol affect the behaviour and attitudes of their teenage children? As you might expect, they do, and the effect is strong. What is most scary from their work is the high prevalence of really risky drinking in both teenagers and parents, and the complete lack of understanding of the risks.

A team from Kinsale community school in Cork, looked at awareness of male suicide, and access to services and education about suicide. they found a good level of awareness, but quite big difference between young men and young women in how they respond to their distress. The boys, as has been shown before, tend to bottle it up.

Several groups looked at obesity, diet and exercise. A team from Loreto Abbey looked at how much people knew about the calorie content of common foods. A group from Ardscoil Ui Urmoltaigh, in Cork looked at easy ways to detect spiked drinks. A group from St. Colmcilles’ in Dublin looked at how much exercise was needed to use the calories in common snacks – far more than you might expect, by the way. A group from Mount Sackville in dublin looked at calorie labelling and its effect on vending machine sales. The group most affected was the small proportion of kids who got most of their lunch time food from the machines.

The most original title I saw was definitely ‘On Wednesday we wear pirate hats’ a piece of experimental sociology from Avondale in Wicklow. They established, as social norm in their school, that people wore black paper pirate hats on Wednesdays – a graphic example of the power of persuasion!

Overall, these young men and women showed a great awareness of the real challenges facing many of their peers. Those who go into the Young Scientist, besides being bright, tend to be confident and outgoing. They realized clearly that not everyone is like that. They see, day by day, the effect of inactivity, obesity, alcohol, drugs and poor mental health on the lives of their peers, and they document that effect beautifully. Most of those I met have a very sophisticated, what we might describe as ‘grown up’, understanding of their world, and of the people in it. They also have lots of good ideas on how to improve it.

The Irish government is also good at identifying risks. We have pretty good policies on obesity, exercise, alcohol use, and sexual activity. However, if doing anything to implement one of these policies causes any bother, we just fold over and lie down. There are still vending machines in most Irish secondary schools selling junk. We still have far too little PE on our schools, secondary and primary. Proposals to stop Diageo and friends peddling alcohol to teenagers with pictures of instantly recognizable GAA and rugby stars have run into the ground. An ex-president of the GAA described this, quite correctly, as ‘spineless’. One very prominent ex-rugby star, Brian O’Driscoll has even signed up as a Coca-Cola ambassador.
Our children deserve better. Frances Fitzgerald, the Minister for Justice, is bringing forward a new bill on children and family relationships, which I welcome. Could we add a bill to support our children in living healthy lives, even if it might hit the profits of multinationals, and the pockets of sports stars?

HSE Service Plan 2015

The HSE Service plan is out today, and you can read it here. I’ve just finished reviewing it for the Pat Kenny show on Newstalk.

Some key points

  • Some money to reduce waiting lists in acute hospitals
  • Some money to support moving patients out of hospitals in to home care or long term care
  • Hospital groups to happen
  • Palliative care service in the Midlands for the first time
  • Better access to diagnostics for GPs – ultrasound now, more services in 2016
  • Some increase in spending on disability services and mental health
  • 0.7% increase in spending from 2014 outcome
  • New use of balanced scorecard methods to hold managers to account
  • More investment in ICT

All in all the new service plan represents some progress, and a lot of stabilisation. Over the last few years HSE has made much more systematic use of information to monitor activity and track progress toward its objectives. This is elementary good business practise. They now publish monthly performance reports, which provide a great resource for seeing what HSE are up to, and what they had planned.

From my perspective, 2014 was a really hard year for everyone in the services. It started with what I believe were fantasy savings of €666 million, later reduced to a less obviously sarcastic €619 million. Over the year, many measures deteriorated. Trolley counts, which had fallen quite steadily since 2011, began to rise, waiting times for admission began to rise, and even the newly available waiting times for outpatients began to rise. The number of medically discharged patients, often cruelly and unfairly called ‘bedblockers’ rose – and is now nearly 800, the size of a very big teaching hospital.

There were some more positive signs. A pressure sore initiative reduced sores by 70% in the North-East, a great result. There were 13 people waiting over four weeks for urgent colonoscopy at the end of September, but all were seen by the end of October. In the past, these people would have been left waiting.

Looking at the service plan for 2015, it looks realistic. The savings figure, of €140 million will be tough, but can be reached. There is an acknowledgement that both waiting lists and people on trolleys will continue. Having spent several nights myself on trolley in A/E I do not take this lightly, but at least the problem is known, it is being measured, and they will try to manage it. There is more money for mental health and disability services – not enough more money, but perhaps enough to hold things stable, and make some people’s lives better in 2015. There is some extra money for home care packages, and some for nursing home packages (Fair deal), mostly aimed at frail elderly people, too many of whom are sitting in acute hospital beds.

There are some interesting straws in the wind – there is money for new services in general practise, with better access to diagnostics, a new service for managing people on warfarin, and a move to do more minor surgery in primary care. The Medicine’s Management Program are getting more resources, presumably to improve the quality and reduce the costs of prescribing. If this can be made to work, it could be a very big win. Ireland does very poorly on measures of prescribing cost, and generic prescribing, and we spend a lot of money on drugs. This could be the very modest start of a serious shift of resources into GPs and primary care. It’s not big enough, and not fast enough for my taste, but it looks realistic, and achievable.

This is a credible plan. If cost containment, especially in the acute sector, works, and this is a big if, it can be delivered, and will modestly improve the situation for quite a few people.