By Orla Hardiman, Professor of Neurology and Academic Director of the Trinity Biomedical Sciences Institute
Our health needs have changed radically over the past 60 years. But our health system is a piecemeal legacy of the 20th century, when TB was rampant and life expectancy was around 65. We cannot deliver appropriate care for 21st century health problems without substantial reform, and this will require huge structural changes, appropriate investment, and a major political commitment to reform of both organisational and clinical governance.
To achieve this we must move to a modern approach that is driven by data. This is not as insurmountable a task as it might first seem. We already have strong evidence that good data can drive change in a very tangible way. The best example of this is the cancer strategy –which has been one of the major success stories of Irish healthcare. This can largely be traced a political decision to address poor outcomes in cancer. The outcomes were provided by the Irish Cancer Registry, a database that has captured incidence, prevalence and outcome of cancer in Ireland for the past 20 years, thus enabling comparisons with other populations. Using a data driven approach and with appropriate political support, our cancer outcomes have substantially improved, and we now have the infrastructure and personnel to drive a top class cancer service.
Development of the requisite information technology for 21st century healthcare management is urgently needed, including electronic patient records and disease registers. But we also need a formal structure that commissions, drives and harnesses all of the considerable clinical data available within the Irish health sector. One mechanism by which this could be done would be through a National Institute for Health Research (NIHR), mirrored on that developed in England in 2006.
The English NIHR is part of the National Health Service (NHS), and was established with strong political support. It is the force that drives clinical research and data gathering programmes on topics of national significance, and has had a measurable effect on outcomes for patients such as the development of the recently reported “bionic eye” for people with age-related loss of vision.
We badly need a similar entity with a commensurate level of political support in Ireland. This would be embedded within the Department of Health and would have statutory funding to would commission and coordinate clinical and applied clinical research to drive policy change.
To start with, we could then tackle the problems of poor governance and inefficiency. Good institutional governance is very important to maintain standards and control costs. And while we as doctors value our clinical autonomy as professionals, clinical governance should be data-driven and we must establish and adhere to meaningful outcome measures for our clinical activity.
Collection of high quality clinical data using a systematic harmonised and integrated process could quickly identify variances in clinical practice and outcome. This could include whether or not a patient is admitted to hospital for a particular symptom, the length of stay in hospital, the numbers and types of tests performed to make a diagnosis, or even the use of antibiotics to treat some types of sore throats.
While there are many reasons for variance including patient characteristics and complexity, variance can also relate to true differences in practice, such as differences in the utilisation of established clinical protocols, and non-adherence to evidence based practice.
Data driven protocols can save lives, and it should be possible to address variances by supporting under-performing services, and by improving education in the use of evidence based and data-driven protocols. A fully functioning NIHR could achieve this by providing the resources and infrastructure for systematic collection and integration of data that could be used to drive policy and to measure improvements.
In a data-driven environment, political rhetoric surrounding the closure of local hospitals that are both inefficient and sometimes unsafe would not be tolerated. With good primary care structures in place, our hospitals could be built up as data driven and evidence-based centres of excellence, with sufficient clinical activity to maintain the highest possible standards of care. People with chronic diseases could be managed at home without requiring extended hospital admissions.
But this would mean appropriately resourcing our primary care system, with 24-hour access to dedicated primary care teams, including general practitioners, nurse practitioners and clinical professionals, and the extended utilisation of specialist nurses. Primary care clinics could provide basic assessments (e.g. phlebotomy, basic blood analysis, X-rays and ECGs) that currently take place in hospitals. This will be expensive to set up, but in the longer term it would be cost effective and better for patients and their families.
For this to happen, politicians must recognise the importance of outcome data. They must sign up to the necessary investment to enable access to enhanced primary care services for everybody, rather than taking politically expedient options that are not supported by evidence.
With the right political support and strong leadership we can begin the long road towards an equitable health system that will equip us, somewhat belatedly, for the 21st century. This is truly a life and death matter, and our politicians do not serve us well by playing the short term game of electoral politics with people’s lives. The creation of an Irish Institute of Health Research would be an excellent place to start planning for the new vision of healthcare.
This article was originally published in The Irish Times on August 7th, 2015 and is based on a lecture given by Professor Hardiman at the McGill Summer School in July.