Governments doing their jobs are not ‘nanny states’

The IEA, under the guise of the European Policy Information Centre, which operates from the IEA offices in London, has published the first Nanny State Index, described as ‘a league table of the worst places in the European Union to eat, drink, smoke and vape‘.

As you might expect, if you know the IEA, good (low scores) means unregulated, and bad (high scores) means regulated. The highest scores go to Finland, Sweden the UK, and Ireland, in that order. I’m quite proud of that. I believe that states have a role in protecting their citizens from the damage caused by unrestricted marketing of unhealthy behaviours and lifestyles. As many of the costs fall back on the state, there is a perfectly respectable economic argument for this as well.

There is a press campaign, so that journalists, and sub-editors, across Anglophone Europe at least, can cut and paste headlines. Oddly enough, for a project reportedly produced with six partners, and seven collaborators, in other countries, only one, the Visio Institute in Slovenia, now has a report of the index on their website that I can see.

Countries do well on this index by not regulating and not taxing alcohol, tobacco, e-cigarettes, and soft-drinks. The details of the scoring are complex, but quite well explained on the site. The overall scores are plotted against life expectancy, on a page headed ‘analysis‘, and no obvious correlation is shown. No statistics are shown either, and there is no account taken of wealth, the dominant factor in life expectancy, nor of changes over time. This isn’t a very credible analysis. As for references, apparently real men ‘don’t need no stinking references’. Frank de Vocht has done a proper analysis of this, and finds a modest effect, of about five weeks of life per person for every one point increase in the alcohol and tobacco components of the index.

Moving on, what is all this about? EPICENTRE, the coordinating body for the initiative, provides no  information on its funding on its own site. A spokesperson has confirmed that EPICENTRE, is 100% funded by the IEA. In turn, the IEA are coy about their funding, in fact a spokesperson today said they did not disclose the names of their private donors, and would neither confirm nor deny that they still received funding from the tobacco industry. It’s known that they did in the past, and in an index of transparency for leading UK think tanks, the IEA comes out close to the bottom.

My belief, subject to refutation, is that the IEA acts to support the interests of those who pay for it, by arguing against regulation on health grounds. The price of accepting their advice would be many extra deaths, many ruined lives, and higher profits for their corporate funders. This would be another good example of private profits and public costs. I do not think we should pay this.

My own interests, as an academic, and an aspiring politician, are a matter of public record, I fail to see why the IEA should be allowed to hide its conflicts of interest behind a veil of obscurity.

Incidentally it is reported that the UK Charity Commission is now reviewing the IEA, specifically asking ‘whether IEA is sufficiently transparent about the sources of funding for key political activities, and whether some of its controversial political activities are within its charitable objects’, which I would commend.

V0011830 An old wet nurse; symbolising France as nanny-state and publ Credit: Wellcome Library, London. Wellcome Images An old wet nurse; symbolising France as nanny-state and public health provider. Colour photomechanical reproduction of a lithograph by N. Dorville, 1901. 1901 By: Noël DorvillePublished: - Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0

Repeal the 8th?

I’ve been approached by two groups, the Pro-Life campaign, and the RepealEight campaign. Both requested me to indicate my views on the 8th amendment, specifically whether I am for it or against it, from the pro-life campaign, and whether I would support a referendum on the amendment, from RepealEight. This is a key issue for many people.

My own views, which  may not be popular with either side, are not simple, in that I favour repealing the 8th amendment, but oppose unrestricted abortion. I do not claim that I am right, but this is where I am starting from.

Some background first. I’m a doctor, and started my working life as a paediatrician. I spent several years working in the Coombe hospital, mostly caring for very sick premature babies, and a range of babies with congenital anomalies and chromosomal problems. I’m a man, I’ve never been, and never will be pregnant, so I don’t have that experience, but I have seen many mothers with critically ill and dying babies. I have a bit more experience than most people of both the tragedies and the joys of birth. I now work in public health, and a good deal of my recent work has been on intellectual disability, specifically my work with Special Olympics Ireland, and on autism.

In 1983, I was in my final year in medical school, when the 8th amendment was brought in. The purpose of this amendment was to prohibit any legislation regulating abortion in Ireland. Abortion, was, and is, illegal under the 1861 Offences against the Person Act. At the time, my father, a solicitor, and many other lawyers, including Alan Shatter, argued that the effect of the amendment would be to bring in a right to abortion, under the constitution. This subsequently turned out to be correct. Truthfully, I cannot now remember how I voted in 1983. I do remember watching SPUC in action, and later their trying to use the courts to muzzle people. At the time, I disliked them, – they did little to protect any child, born or unborn.

So, now, I think the 8th amendment was a bad idea. Abortion ought to be the subject of legislation, not an item in the constitution. Placing it in the constitution let the Oireacthas off the hook. There will be, almost certainly, be a vote to repeal it, and it will almost certainly fall. Both of these I support.

The hard question is what ought to replace it. At the moment, in the UK, abortion is available on demand. My view is that once a woman is pregnant there are two sets of rights involved – hers, and the baby’s. I also believe that rights impose duties, both on individuals and on the wider society. If they do not, they are vacuous. I do not believe that any right, of anyone, trumps all others in every circumstance. Managing rights, and the conflict of rights, is hard. I also appreciate, very clearly, that I am not ever going to be in the situation of being pregnant and not wanting to be.

What about unwanted pregnancy? I said earlier that I disliked SPUC. This was because for all their rhetoric about protecting babies, they did little to support women who found pregnancy difficult. Women can and do find themselves in bad situations, often because of poverty, which are made much worse by pregnancy. For me, the right social response is to support the woman, not terminate the pregnancy. I accept that others disagree, but having cared for a baby born at 22 weeks, and seen her parents interacting with a child who was going to live for less than an hour, I believe strongly that babies have rights, both in-utero, and after delivery. As a country, we have obligations to vindicate these rights, but also to balance these with the rights of the mother. This may not be easy, but there is no guarantee that a serious rights based approach will be easy.

In other countries, many babies affected by congenital anomalies, and chromosomal anomalies are terminated, purely because of their condition. I am unalterably opposed to selective termination based on gender, race, anatomy, or chromosome count. I take a firm rights based approach to disability, and this includes a right to live. Please try to imagine what people with Down syndrome think of quasi-routine termination of babies with trisomy 21, or better yet, ask someone.

What about fatal foetal anomalies? By far the commonest of these is anencephaly. This is a condition in which the brain fails to form. Such babies miscarry, or die  very shortly after birth, and are now usually diagnosed on the first routine ultrasound in pregnancy. I do not see any realistic objection to termination in such a case if that is the mother’s choice. Other conditions are proposed, as ‘fatal foetal anomalies’, for example Edward’s syndrome (trisomy 18) and Patau’s syndrome (trisomy 13). Many children affected by these two disorders die within the first year of life, but some do not. I do not believe that these, and the many similar disorders, are in the same category as anencephaly.

Are there difficult cases? Of course. The tragic death of Savita Halappanavar is a good example. I said earlier that it is hard to balance the rights of mother and baby. This may show what can happen when you fail to do do the work of finding the correct balance (there were several distinct issues in her care, besides her pregnancy). For me, (bearing in mind that I am not an obstetrician), a reasonable treatment for a woman in her condition might have been a termination. What about another tragedy – a woman raped, and pregnant, as in the X case? I try not be a hypocrite. If my daughter were in that situation, I would ensure that, if she so chose, she could have a termination. I’m well-paid, well-educated, and well-connected. I would have no difficulty arranging for this. I don’t see that I can argue that other women should be denied this.

I think we need comprehensive, but quite restrictive, legislation on abortion. I respect most of those who disagree with me, on both sides. I admire the courage of James Reilly and the Fine Gael/Labour government bringing in the Protection of Life During Pregnancy Act 2013. This Act is, literally, tied in knots by the constitution. It needs to be un-knotted.  If the Oireachtas does not do it, I think the courts will, perhaps following the very recent judgement in Northern Ireland.

Manifesto review – the lessons

I’ve now written eight short pieces on the health manifesto’s from each party. Each is linked to from the table below, as are the corresponding manifestos, if you want to read them. This has been an enlightening experience. Niamh Griffin, the Irish Mail on Sunday health correspondent, spurred me on to finish reviewing the manifestos, by asking me to contribute short notes to a piece which will, I think, appear tomorrow (Sunday Feb 21st). The blog posts are the long versions!

Two things strike me very forcibly. First, there is already a high degree of consensus on two propositions :-

  1. The Irish health care system is unfair, and needs to move to universal care, equally accessible to all.
  2. The system needs to focus more on primary care than at present.

There is also wide agreement on a number of more specific policies. Most parties intend to reduce or abolish prescription charges. This is good, because these charges discourage the use of essential medicines. Taxes on sugary drinks are popular, as are a range of public health measures, on alcohol, smoking, and promoting physical activity, especially in the young. Drug policy is more divisive, ranging from more Garda work to prevent the sale of drugs (FG) to a health based approach to drug policy (Green Party). However, every single party wants a wide range of public health policies and measures to tackle major health problems.

Free GP care is also popular, whether it be for under 18’s now (FG, Labour, Social Democrats), for everyone, but to be phased in over (SF, Labour), or vaguer plans in the future (FF), most of the parties support the idea. They are much hazier about what it means, how to do it, and how to pay for it.

What is being missed out? Several parties (FG, Sinn Féin, and People before Profit) want to abolish HSE. They believe, I think, that HSE cannot be fixed, and that no change can be made in Irish health services while it continues. I can understand why people are intensely frustrated by HSE. I am often driven wild by its latest messes, but it is the only game in town. If we choose to remove it, it will take a minimum of three years before the health system settles down enough to make any further changes. If you doubt this, look at the NHS. The biggest weakness of the NHS is the endless reorganizations which have crippled it. It’s easy to re-draw an organization chart – any idiot can do it, and several have. The hard bit is changing what happens in clinical encounters. This is the bit of the health service where the patient meets the clinician. This is also the bit which matters.

A second common error, and one which afflicts all the parties, though some less than others, is the continued obsession with hospitals, and hospital beds. It’s not that hospitals do not matter. Of course they do, and they have a vital role in any health care system. However, in Ireland, the balance between care in hospitals, and care in general practice, is wrong. Too much is being done in acute hospitals, and far too little activity, and far too little money goes into general practice. This is part of the reason for the long waiting lists, the queues in A/E, and the ludicrously high bed occupancy rates in our hospitals. We do need some more investment in our hospitals, but we need a lot more investment in general practice. This will take several years at least.

Many of the parties support the idea of giving GPs further access to test, x-rays, ultrasound, and so on, as well as moving more minor surgery into general practice. The capacity to take on more work in General Practice is somewhere between limited, and non-existent. There are far too few training posts in Ireland (full disclosure, I was involved in a plan to bring ACRRRM, an  Australian training body for GPs, to Ireland, but we did not succeed). There are also not nearly enough staff (nurses and other health professionals)  in most general practices to take on the necessary support roles for GPs. It will take a lot of time, and a great deal of political effort, to fix this.

There is also a fundamental confusion between primary care and general practice. In Ireland, when you ask people about primary care services, the only most people use is general practice. There are other bits of primary care, and, for historical reasons, these are now quite separate administratively from general practice. In most countries, primary care is much better integrated than in Ireland, and the managerial tangle is a serious obstacle to progress. GPs are, almost all, small business owners, or employees of small businesses, with relatively few staff, often 1 nurse per 2 GPs, and a secretary. Most nurses now working in the community are public health nurses, employed by HSE, and reporting, ultimately, to one of nine community health organizations. Home helps, community physiotherapists and occupational therapists, all fall into the same structure.  There are also separate mental health structures, with psychiatric nurses, psychologists, and psychiatrists working in their own silo. This all works better than it should, mostly because of personal links between professionals, but it is often very clunky.

Primary care teams were meant to fix this. The idea was that the GPs, public health nurses, and the other health professionals, would meet regularly, and work together to meet many of the needs of their local population. By and large, they have not worked. With some exceptions, their impact on health care has been limited. The key deficit is, I think, one of governance. Who exactly, is responsible for patient care? At the moment, this problem is bypassed, because many of the interactions are short

Blog postLink to manifestoDirect link to files
Renua IrelandManifesto textRenua Ireland
Social DemocratsManifesto textSocial Democrats
Fianna FáilManifesto textFianna Fáil
AAA - PBPManifesto textAAA-PBP
Green PartyManifesto textGreen Party
Labour PartyManifesto textLabour Party
Fine GaelManifesto textFine Gael
Sinn FéinSinn FéinManifesto textSinn Féin

Manifesto review 8 – health and Sinn Féin

Sinn Féin have not one, but two relevant documents. The first is their 58 page manifesto , and the second is their 82 page health policy, Better4Health, from late last year. Both are covered here.

Better4Health starts with ‘Universal Health Care, not Universal Health Insurance, is the solution’, which is now pretty much common ground amongst all the parties except Fianna Fáil. A huge amount of work was done on costing these proposals, but ran into some challenges .My favourite is this ‘Our costing development work was further frustrated by the staggering deficit of data held centrally by either the Department of Health or the HSE. On a number of occasions, they simply would not, or could not, provide the basic data required to determine what we are currently delivering for our spending. This in itself is of serious concern.’

Their analysis of overall health expenditure is spot on. We spend quite a lot, and we do not get a reasonable return from this expenditure. Their solution, which is to spend a lot more, does not seem obviously reasonable, or indeed likely to work at all.

In detail, they divide their solutions up under three headings – Equality, Capacity and Funding. They will hire 6,600 more staff, almost all in hospitals, remove prescription charges, and provide free GP care for all on a phased basis. As far as I can see almost none of the extra staff will be actually working in general practice, which is a major omission. They plan only 200 more practice nurses, which is a drop in the ocean, and an extra 40 trainees a year, which will not keep up with retirements.

They will bring in taxes on sugary drinks, minimum unit prices for alcohol, and more resources for drug treatment. They will also regulate food marketing. They have some good ideas in mental health, including specific suicide prevention actions, more resources for children’s mental health, and better access to counselling in primary care.

Overall,this is a policy which identifies problems, and some solutions, but fails to fund some of the key actions. For example, under managing chronic disease, they suggest hiring more consultants, care plans for people with asthma, and screening for coeliac disease. This is a rag-bag of ill thought out ideas, and will not address the huge challenges facing our health services in dealing with long-term illness. There are good ideas here, and the overall goal – universal health care, is worth reaching for. They have put a lot of work in, perhaps more than any other party, but they have missed the mark.

Manifesto review 7 – health and Fine Gael

Full disclosure – I’m a Fine Gael member. I’m not very impressed with the health policies in their manifesto, as you will see, but I support them, partly because I approve  of the way they pulled our economy back from the edge from 2011 onwards.

Fine Gael’s manifesto is out. It’s a 140 page tome, with a long section on health policy. Like Fianna Fáil they talk about health in four headings, and an appendix with detailed costs. Unlike Fianna Fáil, they have been much more systematic in what they cover. Their overall message is that they have a ‘plan for Universal Healthcare – for access to quality preventative, primary, curative, rehabilitative and end-of-life healthcare that is timely and affordable for everyone’. This is very comprehensive, and ambitious. I’m not going to list every item, but will focus on some highlights and comment on these.

More Resources and Staff and Better Infrastructure for Health Services

They plan to increase health spending steadily, all going well, over th next five years. They will hire 4,400 more staff, although few of these seem to be in community services, and very few in general practice. They will encourage HSE to work with the private sector to roll out a decent health IT system, including electronic health records. Renua is the only other party to suggest this critical piece of investment. In 2017, there will be a capital review and a bed capacity review, which will guide hospital bed numbers. Both of these are sorely needed. They still plan for a competitive private health insurance market, which would be nice, but would not be a priority for me. Their plan is to fix the health care system, as outlined in the next section, come up with a better funding model, and then move to universal health care.

 Health Reform Programme

They still plan to abolish HSE. This is  really really bad idea. Having worked there, part time for two years, I quite understand why they feel like this, but it is still a bad idea. It is is not possible to simultaneously abolish HSE, and reform the delivery of health care. HSE itself is far from perfect, though it is improving, but abolishing it will freeze all health service change for at least three years. Making hospital groups work (this is at all, not better)  is not a bad idea, although this should have been done two years ago. The notion of keeping the voluntary hospital boards, and setting up hospital group boards, is entirely incoherent, and a recipe for chaos. Reducing drug costs, and limiting prescription charges are good ideas. They suggest an expanded role of nurses in hospitals, which I approve of, but say little about nurses in primary care. A stronger system of performance management for hospitals might be a good idea, although there is little mention of clinical governance. They mention open disclosure, that is telling patients about errors, which I strongly support.

A Decisive Shift Towards Primary and Community Care

For primary care, Fine Gael propose more primary care centers, supports for general practice, including more training places, and a wider range of services, as well as more chronic disease management,  in general practice. Where it falls down, with a bang, is in the idea of setting up multi-disciplinary teams in the primary care centers, with no mention of the GPs. Clinical governance is essential for primary care, and most of it, in my view, needs to come from the GPs. They plan free GP care for those under 18, which I believe is not feasible without quite a lot more GPs and a lot more staff in general practice. No serious budget for this is suggested anywhere.

Mental health gets its own subsection. There’s a lot of detail, but key pieces are more resources, more of a focus on prevention,and early intervention, with a number of specific programs identified, including the Jigsaw program, and some of the community based programs developed with Genio over the last few years.

Improving the Health and Well-being of the Nation

Key proposals here are the new Alcohol bill, a sugar tax, further reductions in smoking, an expanded vaccination program, and support for physical activity, obesity prevention and sexual health, and and a ‘Fit for Work’ program (to support people with illness and disability in working). I don’t like one phrase ‘to consider additional measures to tackle excess alcohol consumption and misuse’ which comes straight from the drinks industry. (What we need is a reduction in overall consumption too). They also undertake to support a range of clinical initiatives, cancer care, the national maternity strategy, dementia care, rehabilitation, and palliative care. These are, mostly, sensible suggestions, and I would support them, by and large.

Overall, there are good ideas here, but also some impressively bad ones. It is far too hospital focused. In fairness, so are many Irish people, and much of the Irish media, but it is still a mistake. There is too much emphasis on changing institutions and organizations, and little sign that they realize that the hard bit, and the important bit, is changing what people actually do on the ground. There are ambitious plans for general practice, with no real resources behind them. Could do better!


Manifesto review 6 – health and the Labour Party

Labour’s manifesto covers health in a section labeled ‘Standing Up for Families & Communities’ which gives a clear idea of the context. The health section is called ‘A New National Community Health Service’. The idea is to have a single tier system with free access to care from GP to hospital. There will be a Minister with specific responsibility for this work. Like Renua, they suggest setting up a National Health Forum to ‘ develop a shared approach and understanding on the future challenges’ for our health services, which seems a good idea.

They plan to recruit 5,500 more staff, and lower the current charges for prescriptions, both  the GMS and on the drug prescribing scheme. Free GP care will come in over five years, along with community based chronic disease programs, to be delivered by GP’s, nurses, and others. No mention is made of the governance of these programs. This would require 1,428 more GP’s. I’ve no idea where this eerily specific number comes from, but this is in addition to the 5,500 other staff they plan to recruit.

They will improve access to dental health services, and bring in the National Maternity Strategy. Both of these seem very good ideas. For mental health, they want to focus on early intervention, especially for young people. They will provide access to counseling services, and better treatment for those with so-called ‘dual diagnosis’ – drug or alcohol addiction, and a serious mental illness, a much neglected group of patients.

For hospitals, they plan 1500 extra beds, to improve access, and reduce A/E wait times and waiting lists. They will also move to activity based funding – Money Follows the Patient, and and a new, much tougher system of financial and managerial accountability.

They support a sugar tax, and tighter controls on food marketing, with much better food labeling. They will bring in mother and baby clinics, to do what is left unspecified, and increase support for physical activity in children.

Almost no details of costs are given, apart from a total of €2.975 billion. This isn’t broken down in any way, but may well be in roughly the right ballpark. There is no real discussion of health management, or ways of improving health care delivery.

These polices are well focused. I am fairly sure that only a very large increase in activity and resources in general practice, primary care and community care, can untie the knots in our health services. However, there is a lack of serious thought about what these services might look like, how much they might cost, and who would provide the necessary clinical governance for them. My own view, for what it is worth, is that this can only be done by GP’s, but in any event, someone has to do it. I doubt we can afford a large increase in both hospital resources and general practice resources. They do not consider widening the roles of practice nurses either, but there is compelling evidence that, working with GP’s, these professionals can provide expanded good quality care for many people with long-term chronic disease.

Manifesto review 5 – health and the Green Party

The Green party manifesto has some good ideas on health. The ‘social affairs’ part of their manifesto is headed ‘Efficiency in Everything we do’, and it’s not a bad summary. Their key idea is ‘to develop patient-centred care, to prevent problems before they occur, and to create a world class health care system that is cheaper and more efficient’. This is laudably clear. Do they outline a credible path?

In part yes, but also in part no. One interesting thing about reading a stack of manifestos is that you get an idea of whether the people who wrote them are actually familiar with modern health care delivery or not. The Green Party fails on this. Ideas such as advanced public health nurses, providing care at home; paramedics going to homes, and keeping people out of hospital; combined physical and mental health polyclinics; do not suggest a strong grasp of what modern health care is about. There is also very little on social care, little on care for the elderly, nothing on chronic disease, little on general practice, and no suggestion of removing drug co-payments.

They plan to replace HSE with Community Health Organizations, ‘which will include a balance of community and patient participation advised by health care professionals. This is possible, but would be very disruptive. They have some good ideas on disability, but surprisingly do not suggest individual care budgets. They also support a sugar tax, which I welcome, better food labelling, and limits on marketing of food to children – the ‘Sydney principles‘.

Their most innovative ideas are on health care financing and funding –  They want a single-tier health system, funded largely from general taxation. They support multi-annual budgeting, Activity Based Costing and blended Capitation Schemes, to encourage efficient use of resources. These are really good, really radical (by Irish public sector standards anyway) ideas, which could make a big difference.

They say little about general practice, apart from suggesting  more investment in services to allow for ‘minor procedures and specialist services’ to take place outside of hospitals. This kind of misses the point.

Overall, they have some good ideas, and a plausible vision. They show little sign of knowing much about the detail of providing modern health care, and there are no detailed costs. They suggest €625m over five years, which I think could only cover a fraction of their aims.  Some of the financial changes proposed could have a big effect on the quality of financial management within the sector, and these are very welcome.

Manifesto review 4 – health and the Anti Austerity Alliance/People Before Profit

This will be quick. The AAA/PBP health policy is short. The one line summary from their manifesto is

  • Creation of a National Health Service free to all at the point of access, with greater investment in all areas including mental health, and the promotion of alternative treatments over prescribing medications

The full version is only slightly longer. They do propose reducing health inequalities by reducing wealth inequalities, which is a good idea, and would have some effect. They plan to abolish HSE, and replace it with ‘democratically elected Community Health Councils and an Independent Agency of Public Health Promotion that works with a responsible and accountable Department of Health’. This is not a good idea – abolishing HSE would paralyse health care change in Ireland for a minimum of three years.

They suggest building more primary care centres, which would be run by public servants. They do not mention general practice once. Like almost everyone else they want to remove prescription charges, although they are not clear about which ones – medical card, or all charges. There is a heavy focus on mental health, which is welcome, including making non-drug therapy more widely available, and a commitment to implement Vision for Change.

There are no costs, and no details given about the implementation of these policies. All in all a pretty poor effort. It may be more a negotiating position than a serious policy.

Manifesto review 3 – health and Fianna Fáil

Fianna Fáil have published their manifesto. I’m going to concentrate on both the strengths, and what I see as the weaknesses of their health care proposals. The title given to this section of their manifesto is telling. ‘Support a publicly funded health care system’ is what it says, and that is pretty much what you get. The presentation is a bit scrappy with 32 promises, some very general, such as ‘Reform the Health Budget’,  ‘Expand GP Care’ and ‘Improve the Health Service Executive’, and some very specific, such as ‘Increase funding for the Fair Deal scheme’, ‘Recruit an extra 500 Consultants’, ‘ Employ 4,000 more nursing staff’ and ‘Hire an additional 50 dental surgeons’.

There are some definite swipes at the current Government, notably ‘Reduce scheduled waiting times to the international standard of six months by re-activating the National Treatment Purchase Fund’. Translated this means moving resources to provide care in the private sector, so reducing waiting times, by restoring one of their pet schemes, from an earlier FF/PD government.

There are many positive features – for example the commitment to barring privatization of existing service providers, including hospital groups, and the health insurance function. For HSE, they are committed to making it work better, although there are some weasel words about removing under-performing managers to posts more commensurate with their capabilities’, whereas what is needed is the courage to lose some of these people. There is a strong, and welcome emphasis on primary care, community care and General practice, with items like ‘ Rebalance the Health budget towards Primary Care’, ‘ Boost Community Pharmacists’ and ‘Support General Practise’. They propose recruiting an extra 250 GPs by 2021, which is, at least, a start.

There are some nods to public health and disease prevention ‘ Establish an Office of Alcohol Control’, although this is silent o n reducing the overall intake of alcohol, ‘Make Smoking History’, which builds on Micheál Martin’s greatest achievement when he was Minister for Health, and ‘Promote Healthy Living and fight obesity’ which includes a personal favourite of mine – a sugar tax.

There are some innovative ideas. They propose to ‘ Establish a new National Mental Health Authority’ on the lines of the Road Safety Authority, to improve mental health, and reduce the toll of suicide. They also commit to finishing the implementation of ‘A Vision for Change‘, which would be a very welcome development. It’s not clear whether the 2,700 extra staff they propose to hire here are already included in the various others announcements of extra staff elsewhere in the manifesto. I’ve asked for clarification on this and will update when I get it. They propose improving care for those affected by cancer and dementia, and they commit to establishing proper neuro-rehabilitation services. All of these are welcome.

Taken all-in-all there are good parts, and some good ideas, but there is no trace of an overall vision. Much of it harks back to the past, for example refurbishing HSE, and re-establishing the NTPF. They want the service we have now, but with some of the rough bits smoothed. These are not bad ideas in themselves, but they would leave all the (expensive) perverse incentives in our health-care system firmly in place. We would still have a  very unfair two-tier system, and it would still be hospital focused. General practice is, at least, acknowledged, but I’m not sure that tits central role in modern health-care is understood. The phrase ‘universal access’ occurs only once in their manifesto (p 24), and there it refers to ‘universal access’ to fast and reliable broadband! These policies will not fix our problems.

Cleaning in hospitals – Holles St. and HIQA

Two days ago, HIQA, the Irish health and social care regulator, published their latest report on Holles St  – the National Maternity Hospital in Holles, St, to give it its full title. This is a very busy maternity hospital, delivering 9,000 babies every year. I’ve just given an interview to Pat Kenny on Newstalk about this,

The core of the report is this ‘During the unannounced inspection on 7 October 2015, a number of high risks were identified, the composite of which presented an immediate high risk finding. Risks were identified regarding infrastructure and facilities, safe injection practices, environmental hygiene, the cleanliness of patient equipment and waste management. Cumulative findings were such that HIQA deemed that a re-inspection was necessary within six weeks’.

HIQA is a regulator, not prone to dramatic exaggeration, and this is very strong language by their standards.What prompted these remarks?

There are quite a number of findings in their report, some of which are common observations,  familiar from previous reports, and from reports on other hospitals. These include failing to comply with best practice in preparing IV drugs, limited storage space, use of corridors for equipment, and cramped sluice rooms on wards. However, all of these are noted in many other Irish hospitals, as a glance over the many other hygiene reports on HIQA’s web site will confirm.

What stood out for me, in the Holles Street report, were phrases like ‘Overall environmental hygiene in the Delivery Ward was very poor with evidence of organic contamination on surfaces, insufficient dust control measures and suboptimal cleaning observed in most areas inspected‘. In a word, the Delivery Suite was notably, and visibly, dirty.

Previous reports on Holles St. had identified some hygiene problems, but the delivery suite had not previously been inspected. Worryingly, Holles St carries out regular internal environmental hygiene audits. To quote ‘Audit results indicated high levels of compliance in relation to environmental hygiene in the Delivery Ward in August and September 2015. A high level of compliance with desirable cleaning standards was not evident in the October HIQA inspection‘. This suggests a certain willful blindness on the part of the hospital

The management in Holles St. commented that they had two specific problems, first the building itself is old, and was not designed for anything like the current level of activity; second it is hard to clean the Delivery Suite, because the rooms are in constant use. The first is undoubtedly true, but as to the second, on the day of the inspection there were several unused rooms, and in the weeks following the first inspection, a thorough deep clean was done on the whole Delivery Suite.

HIQA were sufficiently concerned to take the unusual step of arranging another inspection within six weeks. This showed considerable improvements in cleanliness, although there was still some work to be done.

There are three messages here. The first is that Holles St is a safe place to have a baby. They have collected data for many years on outcomes for mothers and babies, and both are good. Whatever the extra risks of a dirty delivery suite, Holles St are getting away with it, so far. Equally HIQA are doing their job, pointing out problems.

The second is that they took their eye off the ball. It is, of course, difficult to arrange cleaning for places like delivery suites, and A/E, where patients come and go unpredictably. The rooms need to be easy to clean. Very specific measures, for example, a quick hit cleaning team, who can swoop in, clean a room, and get out fast, are needed. Such measures are not cheap, but they are necessary, and other places manage it. Holles St’s internal hygiene audits also need to be tougher and more realistic.

The third is a wider message. We tend to assume that hospitals last forever. They do not. What happens in hospitals changes over time, and the types of space needed also change. The new acute block in the Mater is a good example of what a modern hospital ought to look like. Ireland desperately needs a systematic review of our hospital estate, identifying buildings coming towards the end of their useful life, and replacing these in a reasonable time. As it happens, all three of the big Dublin maternity hospitals are due to move over the next decade, but the problem goes far wider.  Too many Irish hospitals are lumbered with a completely out-of-date estate, and we need a far more radical approach to maintaining it and replacing it.