Quality care comes at a cost

Posted in Blog by saraburke on December 9, 2013

We do not need experts or reports to tell us that proper healthcare requires adequate staffing and resources. See column from 24 October 2013. Speaking to nurses the same week as the publication of a HIQA report into the care and treatment of Savita Halappanavar, HSE Director General  Tony O’Brien said: “Although care costs, poor quality care costs more. Patient safety is paramount”.


The HIQA report is damning, finding “a failure in the provision of the most basic elements of patient care”, in University Hospital Galway. It details 13 “missed opportunities to intervene in the care”, of Ms Halappanavar which, if acted upon, could possibly have saved her life.


After the publication of the report, Health Minister Dr James Reilly concurred with Mr O’Brien that “patient safety has to be seen as paramount”, outlining five key areas that need to be acted upon: achieving a patient safety culture; a code of conduct for employers; monitoring progress on implementation of actions required; the development of a strategic plan for maternity services; and mandating clinical guidelines.


The HSE’s July performance report detailed that the Executive will be publishing indicators on a range of quality and safety measures by year end. This is a very welcome development, which will expose the quality of hospital care and allows for scrutiny of standards over time.


There is a common mantra in Ireland that the Irish health system (by this people mean hospitals) is good once you get into it. There is no substance to this frequently cited excuse for the hideous obstacles that exist when accessing our health system, which are greatest for the poorest and sickest. Also, is it plainly wrong as there are very few quality measures collected and outcome measurements are non-existent. Cases like those of Savita Halapanavar, Tania McCabe, Rebecca O’Malley and many more citizens who have been wronged, and in some instances lost their lives in the Irish health system, indicate the opposite.


One of the few areas monitored is hygiene. A recent HIQA report found that hand hygiene practices are well below the expected level and, in some instances, parts of hospitals were filthy. International studies have shown a clear relationship between high levels of occupancy and poor hygiene. That makes sense; it is hard to keep really busy hospitals clean. Irish hospitals are currently working at an occupancy level well above 100 per cent when the international recommended norm is 70 to 80 per cent.


HIQA CEO Tracey Cooper has said that good hygiene practices are nothing to do with money and she is probably right. However, more than 100 per cent capacity reflects an overburdened system which might well have something to do with the continuous cuts to beds and staff. It is fair to assume that despite potential pools of excellence, Irish hospitals are mediocre at best. You might be lucky and get great care in a clean environment, or you might well not.


Good care requires staff. In July 2013, there was 11,320 fewer staff in the HSE than there were at the end of 2007. Speaking after the publication of the HIQA report, Minister Reilly said he would “not accept insufficient allocation of funding for measures supporting safe patient care, despite hugely competing demands on the Service Plan’s Budget”. Speaking that same week on the new tobacco policy (on which Dr Reilly is providing genuine leadership), he said if this is a choice between saving money or saving lives, he was in the business of saving lives. The Minister needs to apply the same principle to quality and safety, ie saving lives, in all Irish healthcare settings.


It would be interesting to know if and how declining staffing levels are impacting on hospital patient care. In the mental health services there are legal staffing levels in in-patient units. In order to ensure patient safety, staff in community services are continuously pulled into in-patient units to fill staffing holes (to the detriment of community services).


There is no such requirement for “physical” in-patient care. The HIQA report highlights how there are 126 obstetric and gynaecology consultants when a need for 191 by 2013 was projected. This figure was estimated even before the 8 per cent population increase between 2006 and 2011. HIQA also detailed how 5 per cent of midwifery posts were vacant in November 2011. Critically, there are no more recent figures on midwives.


HIQA recommends a review of workforce requirements for maternity services, which in turn requires agreement on a consistent model of maternity services which currently does not exist. This requires dealing with issues such whether maternity care could be midwifery led in many instances? If Mr Tony O’Brien and Dr James Reilly are really serious that patient safety is paramount, then they need to be open to the possibility that understaffing may contribute to poor care, that better care requires more staff, and that more staff costs more.

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