Oireachtas Joint and Select Committees
Wednesday, 19 October 2016
Select Committee on the Future of Healthcare
The Cancer Strategy as a Case Study of Health Service Reform: Professor Tom Keane
I remind everybody in the room to ensure that their mobile phones are either off or on airplane mode and to be mindful of the difficulties caused for the sound recording staff when the phones interfere with the sound. I also warmly welcome all those watching the live streaming of this committee meeting this morning.
For this session we are joined by Professor Tom Keane. We are here to discuss the national cancer strategy as a guide for implementing health care reform. I think the programme is generally seen as one of the most successful examples of reform in the Irish health service in recent years. I warmly welcome Professor Keane to our committee meeting. Before I ask him to give his opening statement, I have a few formalities to go through.
I wish to advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable. Finally, members are reminded of the long-standing ruling of the Chair to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name in such a way as to make him or her identifiable.
I thank Professor Keane for joining us this morning. We look forward to hearing his statement.
Professor Tom Keane:
I thank the committee for its invitation to appear before it. The concept of having such an all-party committee looking to the future is absolutely essential, when compared with what has always happened in the past. Coincidentally, I am chairing an initiative for the Royal College of Physicians, Towards 2026, which members will hear about some time in November.
Returning to the implementation of the cancer programme, I thought it would be appropriate to try to go over the lessons learned. This is all about implementation. It is somewhat gratifying for me to look at the latest figures which show that patients who were diagnosed with cancer between 2008 and 2012 have a 60% chance of surviving five years. This compares with a figure of 45% for patients who were diagnosed between 1994 and 1999. I emphasise that this is a team effort. There is a huge number of people involved at all levels of the system, from the Department through to the hospitals, doctors, nurses and administrators, and I would like to single out a couple of people for acknowledgement at the beginning. Probably my biggest support at the time when I came to the position was from Tony O'Brien, who was then the director of BreastCheck. He essentially became my deputy, and subsequently associate director of the cancer programme. His knowledge of the Irish system compensated for my lack thereof and, without his help and advice, I probably would have fallen into many dark holes. Similarly, I had three excellent advisers: Professor Arnie Hill for surgery, Professor Maccon Keane from Galway for medical oncology and the late Professor Donal Hollywood for radiation therapy. After I left, the programme, as members know, was looked after by Dr. Susan O'Reilly, who is my friend and colleague from Vancouver. She has now moved on to higher things, and the programme is now led by Dr. Jerome Coffey. I am delighted to see it in such good health and progressing.
I will move on to the lessons learned. The first big lesson is all about communication. Communication probably took up 50% of my time when I was there. The media were ever present, even outside the front door of my house when I came out in the morning whenever a controversial decision was being made. I became quite familiar with the surroundings of Leinster House and got to meet virtually all the Deputies present at that time. I appeared before the health committee, which gave me an opportunity to have a frank and open exchange with people in the political system about what we were attempting to do. Communication with the clinical community in Ireland is difficult, and I used the colleges - the Royal College of Surgeons and the Royal College of Physicians, and the faculties within them - as a bridge to meet the medical leadership in Ireland.
This is an underused opportunity in terms of communicating change. In the colleges, as I discovered with the recent initiative, there exists essentially the main medical leadership for the country. There is a huge opportunity to have dialogue and influence with clinicians through the college mechanisms. Similarly, I would say the Irish College of General Practitioners is another body which is underused as a communications tool. I found it incredibly welcoming, eager to be engaged and generally surprised I was bothering to talk to it.
The issue of dealing with the public sector unions was potentially huge for us, given that we were going to require relocation of nursing and other staff in multiple hospitals. Again, I found through sitting down and talking, explaining what we were doing and what we hoped to achieve, and outlining principles of fairness that we would adhere to as we went forward, that ultimately I received significant co-operation without any major public disarray. Communication about change is the first, and by far and away the most important, priority.
The next important issue is leadership. Leadership occurs at multiple levels when change is being made. Obviously the focus was very much on me as the lead person, but the leadership at local level was invaluable. The vast majority of oncologists in Ireland have been trained elsewhere. They recognised that what we were putting forward was correct. Even though it might not have suited their local jurisdiction, most of them in their hearts and souls knew this was not just an idea but an evidence-based idea, and that we were bringing forward change supported by strong evidence rather than a political whim. Leadership at the political level I will come back to later, but I must acknowledge, and many committee members probably know, this was almost a pet project of the former Minister, Mary Harney. She was the person who recruited me to come. She was the person who drove most of the change. I have to say that at the time her support and the support I got from the Government was invaluable. I did not have to fight any political battles and I could focus on the job at hand.
With regard to support from the Department, and senior officials in the Department of Health, this is another important community. They were very supportive and, in many ways, the cancer strategy had been fostered partly from within the Department so it had huge buy-in. We were fortunate we had buy-in at multiple levels. We had a strong evidence base for making these changes even though, I do not know how many committee members recall, there was much difficulty in some parts of the country. On my first visit to Leinster House there was a very large demonstration on Kildare Street and I had to be taken in the back way because people were afraid they would recognise me.
Change in the medical environment, whether in Ireland, Canada or anywhere else, cannot be forced unless it is rational and supported by evidence, and people are willing to engage in dialogue to bring things forward. There is an issue about dialogue in Ireland. I was aware there was a real risk when I came regarding the strategy document, which was an excellent document produced over two years by the national cancer forum. I regarded the document as sacrosanct and I refused to reopen it. The danger I saw was that the risk of endless talk would pre-empt any implementation strategy. I was much criticised for refusing to engage in a discussion on the strategy because I knew once I opened up the strategy then basically we would end up talking and I would spend my time in Ireland talking and not being action-oriented.
Another issue that was important for the cancer programme was the framing of the discussion. Many committee members are aware that at the time there was a series of horrific instances of misdiagnosis, mainly around breast cancer but not exclusively. I had made it clear to the then Minister, Mary Harney, that when I came I would refuse to engage on the subject of things that had happened before I had come. I did not get drawn into many of those discussions, in fact I refused to engage, and I focused entirely on the future, saying if we had a better system these things would not arise.
There is another issue regarding cancer, which is misdiagnosis. There is no perfect system for diagnosis in the world and a low level of misdiagnosis occurs in even the best system. It was important to communicate to the public and media that a misdiagnosis, and this is particularly around mammography, did not amount to negligence or incompetence, and that there is a low level of misdiagnosis simply because one is looking for needles in haystacks, and at a certain level the discriminant ability of the technology and the human mind means is impossible to be 100% accurate. This is important to recognise.
Regarding the level of evidence we brought to bear, I would say that in 80% to 90% of it there was significant evidence in the international literature and from other jurisdictions that what was happening in Ireland was not best practice. We were able to point to comparators at the time. Ireland was in the bottom quartile of the OECD tables for cancer outcome. It was not as if we were arguing from a point that Ireland was doing really well and therefore we should leave everything alone. There was a very strong argument that we were doing very badly. The tragedies around misdiagnosis helped to focus the public mind on the need for change.
Several other issues are important in change, and these include talking to people who know what the problem is. I was fortunate in being able to engage with a number of expert groups here, which saved me huge amounts of time and effort. I met the Irish Thoracic Society, which is made up of most, if not all, of the respirology community responsible for diagnosing lung cancer in Ireland, and it had a clear picture of what the issues were with regard to delayed diagnosis of lung cancer. I took the recommendations and we debated them, and, essentially, we moved to put in place rapid access diagnostic clinics throughout the country, which have been incredibly successful in granting general practitioners rapid access for their patients who have red flag symptoms suggestive of lung cancer.
Similarly, the coloproctology society, which represents most of the surgeons involved in colorectal surgery but particularly rectal cancer surgery which is highly complex, were willing to engage and agree that rectal cancer surgery should only take place in eight hospitals. Without their support it would have been incredibly difficult. Many of the changes were supported by the main community, even though there might have been individuals who, at a personal level, saw their situation being potentially negative.
Another issue is building trust. This is something which must be earned. We had a strong sense of the need to be accountable and very transparent in what we were doing, and to demonstrate integrity at all levels. The programme managed to achieve this.
It built a trust within all of the communities that we were dealing with that, whatever else we were doing, we were genuinely motivated to do the right thing for the country.
I will turn to the necessary authority and resources. Uniquely, no individual in a clinical leadership role previously had been given the level of authority that was given to me to allow me a free hand in making decisions. I did not have to wade through layers of committees. Even though I was technically a part of the HSE, I was functioning in large part outside it, in that much of the drive and energy for the programme emanated from the Department of Health.
Resource issues will always be paramount. The cancer programme got significant additional resources in 2007 and 2008 before the financial collapse, but a considerable part of the programme's funding was a mobilisation of existing funds. Whenever we closed a programme down in hospital X, we took the money that had been funding it and moved it to hospital Y. Historically, this has been difficult to do. Essentially, we moved the money to follow the patient or to where the patients were going to be.
I could go on at some length. Nearly all of the lessons learned in implementing the cancer programme are applicable to any major health care reform that is going to happen in Ireland. I will leave it there for the members' questions.
I thank Professor Keane for attending. I wish to ask a couple of questions about the funding being separate, which he touched on at the end. Did he receive initial funding to set everything up and, as programmes were closed down or moved between areas, their funding was also moved to keep the show on the road?
Will Professor Keane clarify the timelines? The strategy document was prepared over two years, but was that the first action? Was it accepted by the Minister of the day as the way forward? How long did it take from the document's inception to the time the programme started?
A major issue was the choosing of eight hospitals. How did that decision come about? Will Professor Keane also elaborate on some of the political barriers he came up against and how he dealt with them?
I thank Professor Keane for his comprehensive overview. As a trade union representative, I attended a number of his presentations. There was early buy-in from the trade unions. That was essential. It would even have been the case in advance of Professor Keane's appointment, as the parameters for the buy-in had been laid down as part of a national wage agreement that had been negotiated previously in recognition of the fact that significant change would be required.
Professor Keane mentioned that he had been given autonomy. To follow on from one of Deputy O'Connell's questions, to what extent was Professor Keane able to operate his own budget or was his work dictated - I do not mean that negatively - by the Department?
Professor Keane referred to how he operated separately or in tandem with the HSE. Does the structure of the HSE lend itself to the type of ground-breaking change of which Professor Keane was in charge? Has he suggestions on how to better match the HSE with large projects like the national cancer control programme, NCCP?
I welcome Professor Keane. I was around for some of the debates on the implementation of the cancer care strategy and there was, by and large, buy-in for the project. This was for a number of reasons, primary among them being that our cancer care was not what it should have been or what we as an ambitious country had hoped it to be. Let us be clear, in that we were coming from a low base, so there was the potential for a quick improvement that the public could see and the politicians could support. The clinicians and professional organisations recognised that change was required.
Professor Keane referred to the national cancer forum as being the body that devised the strategy. Was that engagement, the strategy's development and then its implementation by Professor Keane a model whereby many issues, including the perceptions of the public, politicians and various stakeholders and vested interests of what was required, could be addressed? Their support came in advance of the strategy's publications. Was this model helpful?
As Professor Keane knows better than anyone, we have a complex health system. Public and private are intermixed and general practitioners, GPs, are sole employees. Did Professor Keane examine the private element of our capacity or did his work focus on the public health system? In terms of physical infrastructure and personnel, Ireland is still short of capacity in the public system. Did Professor Keane examine any of these issues to determine whether they could complement one another?
I am interested in Professor Keane's views on parking ideologies and examining the evidence. Did the national cancer forum or individuals therein come to the table and examine the matter in an evidence-based and rational way as opposed to trying to make the strategy fit into some ideology?
Professor Tom Keane:
Maybe I will deal with the issue of the forum, as it has arisen a couple of times. I cannot be sure about when the forum published its document, but I believe that it was April or May of 2006. The forum had been in session for a year and a half to two years prior to then. It was a group of 20 or so people representing a broad cross-section of the oncology community with some representation from the Department. I never heard people criticising the forum as being unrepresentative. Generally, people accepted that it was a legitimately constituted group. Its report is still available through the Government Publications Office.
The forum's members approached its work entirely on the basis of evidence. They examined best practice. Indeed, many of them had first-hand knowledge of what best practice looked like in other jurisdictions.
It did not have any ideological viewpoint and it did not essentially tread on the public-private issue. I will come back to that later. Essentially, the strategy document was endorsed by Government as the way forward. However, there was a level of detail missing from the strategy document in terms of implementation. It was not an implementation strategy. In that regard, the then Minister and the senior officials in the Department visited a considerable number of jurisdictions, including Germany, the UK, the United States, Toronto and Vancouver, where I was, where they engaged with successful transfer programme operators on what they were doing and achieving. This informed the Minister and the Department, in addition to the strategy, as to where they needed to go. In essence, they decided to model the implementation and many of the features of the cancer programme in British Columbia, BC, which has a similar population in size to Ireland. They saw that much of the BC programme was implementable in the Irish setting, which is what led to me being seconded from the University of British Columbia to Ireland. For me, it was incredibly important to have a strategy document which the cancer agency in British Columbia had already reviewed and found to be excellent. I had confidence that the strategy was good and did not require any further discussion. When people would say we needed to re-open the strategy I would quote General George Patton, "A good plan violently executed now is better than a perfect plan executed next week", because I knew once the strategy was reopened all hell would break loose.
In terms of the timelines, the strategy was published in 2006. Some time later in that year a commitment was given by Government to move ahead. There was a national radiotherapy plan as part of that, that was the so-called Hollywood report, which was separate but part of the same broad initiative. I was seconded briefly in late 2006 to assist in the drafting of the national radiotherapy plan. However, an election intervened in 2007, the date of which I am sure members of the committee will recall. Implementation by the HSE was very slow. When the then Minister, former Deputy Harney, was returned to Government, she decided to retain the health portfolio and I then noticed a dramatic shift in the level of urgency from the Minister and the Department around implementation. There was a period of delay between the publication of the strategy and the decision to have a more rapid implementation plan of two years, which I essentially drafted for the Minister and the HSE in August 2007.
We were not separate from the HSE. At the time, I reported to Mr. Brendan Drumm and I did sit on the HSE executive but my focus was not around being a full and active member of the HSE executive. I was situated in the BreastCheck office complex in Parnell Street and I had significant support from within the HSE in terms of HR and some other functions, which were very helpful. I truly did have autonomy. The Minister had told me I would have autonomy and that she would trust my decision-making but that she and Government needed to be kept in the loop. To that extent I met with the assistant secretary, Fergal Lynch, every month and I gave him a heads up in terms of what was coming. Basically, that interaction was all around communications. At no point did the Minister or the Department ever push me in any particular direction. If anything, they always reassured me to stay the course and to keep going. The committee will recall that there were two Deputies from a constituency in the north west who pressurised the then Taoiseach, Mr. Ahern, and subsequent Taoiseach, Mr. Cowen, to yield on this issue. I received phone calls from both of those individuals telling me to go ahead and that they would deal with the political issues. That political support was incredibly important. I did have autonomy. Obviously, autonomy sounds like one-man rule but we still have a very good process within the programme for prioritising decision-making and for making decisions based on evidence.
On the question regarding public versus private and whether I looked at the private system, the committee will recall that the Health Information Quality Authority, HIQA, was very active at the time I was here. We laid out standards for the performance of breast cancer surgery, multi-disciplinary teams, MDTs and other technical processes. Within a short time the private sector withdrew virtually completely from breast cancer surgery. They essentially saw it as being incredibly resource-intensive and they did not necessarily have all of the personnel required to meet multi-disciplinary requirements. There was no particular friction with the private sector. Many of those involved viewed cancer surgery as being very resource-intensive and felt that in many cases they were not capable of meeting the requirements. HIQA did commit at the time - which I thought was very important - to push for legislation which would ensure that were private hospitals to engage in cancer surgery they would be held to the same standards as the public system. To my knowledge, that legislation was never introduced. I believe that to ensure completeness that should occur.
I was part of the HSE but given the HSE brand was not exactly a popular brand at the time it suited my purpose to be able to operate in an apparently independent mode. The budget for the cancer programme was largely written into the HSE budget by the Minister and her staff. I did not have to participate in the endless wrangling within the HSE over the HSE budget. Essentially, the cancer budget was dropped in on top of the HSE budget by the Department. That was incredibly helpful for me because I did not have to waste hundreds of hours engaging in negotiations with the HSE structure. We were coming from a low base. I found that people were genuinely appalled to see Ireland at the bottom of the league table. We are a sporting nation and the idea that we were at the bottom of the league table and wanted to move up was picked up immediately by the media and it constantly repeated the message. It is probably still true that we are not there yet. While significant progress has been made there is still a lot of work being done and to be done. The cancer programme has not gone away. Owing to the demographic shift in the Irish population in terms of the population getting older Ireland is going to see a dramatic increase in cancer incidence over the coming two decades, irrespective of any prevention measures that might or might not be in place. I think I have covered most of the questions. If I have not, the Chairman might let me know.
Professor Tom Keane:
Fortunately, I did not have to do that and, therefore, I did not have to defend it. That was a decision made by the cancer forum or a group working under the direction of the forum. I would not want to speak to the detail of those discussions other than to say that I was handed a list and informed about the recommendation that was being adopted. I expressed that I thought that was sensible. In an ideal world it might not have looked like that but based on the practicalities at the time it was probably the best solution available.
I was not involved with making that decision.
The point was raised by Deputy O'Reilly on the support of the trade unions in the health sector. If I understand the Deputy correctly, she indicated the issue was considered in the context of a pay agreement.
It was not just a pay agreement. It was pay and productivity. One of the elements was co-operation with a range of measures and the national cancer control programme was one. The other was matching working patterns to service needs.
Professor Tom Keane:
The agreement that was in place provided a framework for this discussion. As Deputies probably know, just having an agreement is not enough to make things happen. The engagement with the significant leadership within the health care unions was civil, helpful and supportive. There was much stuff that was really in the small print that was not necessarily in the agreement. It required a level of trust on both sides that we would keep our word. The last thing we wanted to do was to lose oncology staff when we wanted to retain them. Most of the issues were around relocation.
On that note, there was an overarching agreement that was very helpful but there was also a plan, which was perhaps key to - I will use an awful phrase - the buy-in from health care professionals. They could see where it was going, and it was not seen as change simply for the sake of it. There was an identifiable plan and significant political support for it. That goes back to what we have been discussing at the committee, which is the big bang versus the small and incremental changes. This was more in the line of a big bang but there was a very defined plan for health care professionals to buy into.
This is interesting to me as I did not know the background of what happened at that time with the political establishment, Professor Keane and the elements involved with implementing the national cancer control programme. I do not know if Professor Keane agrees but the first point seemed to be identifying the problem, as there was a big issue with cancer then. It was when Ms Susie Long died because she was a public patient and all the issues that came around it. The problem was very identifiable. It was then about implementing the strategy and getting political support. In a way we are trying to look at that here as a committee, basing our outcome on evidence-based criteria for a national health service free at the point of entry, with equal access for all. We must develop the evidence to put forward to the political establishment that this is the reason we need such an objective and how we can implement it.
Does the witness believe we need somebody from outside to implement any change? He was seconded because of his experience in British Columbia, its history and background, and he was given a particular role. Does he believe we need to consider somebody from outside, potentially, to implement an agreed strategy based on evidence? Professor Keane made a point that really struck me about linking with colleges, speaking with people and negotiating. It strikes me that the Limerick group has linked with the GPs, hospitals, chief executives and other strands of health care professionals in order to make something work. It is something we should look at as a committee if and when we decide what kind of health care system we recommend.
Professor Keane made a point about legislation that has been introduced to ensure the private sector would have the same high standards as the public service.
I thank the witness for his excellent presentation. My question is a follow-up to the previous question in a way. The evaluation panel report in 2014 identified issues relating to legislation and structure. What is the witness's experience with regard to the reform process around legislation? The report also identified significant delays in diagnosis and treatment due to a lack of beds in admissions in accident and emergency departments. Will the witness give his view on a national level regarding bed capacity issues, given his expertise in the oncology area? The report indicated that seven centres for gynaecological oncology in a country of this population of 4.5 million seems excessive. Does the witness have a view on that? Do we need more centralisation of oncology services?
I thank Professor Keane for his submission. He hit a couple of key points relating to leadership, accountability, trust, funding and implementation. Why is the implementation of reform so difficult? Professor Keane's programme seems to be going in the right direction and it is working. He stressed leadership and accountability at the start and they seem to come up in many debates that we have. If this is working in Professor Keane's programme, could it be replicated across the entire health service? One of the major points that comes up constantly is where the buck stops, who is accountable and who is taking leadership and ownership of the system.
Professor Tom Keane:
I will respond to Deputy Collins about whether somebody from outside is required. It was an incredible advantage for me to come in from outside. I did not owe anybody any favours. People were searching through my CV to see which Dublin hospital I trained in and see what side I would be on. In essence, I went out of my way. I refused all social engagements with physicians, golf games and all the usual stuff so I could be seen to be totally impartial and not doing business in the normal way that things are done in Ireland. It is an advantage if one comes from outside but if I had not come from Ireland and I was not as familiar with the Irish system, I probably would have fled after four weeks. There is a complexity about the Irish health care system that is hard to explain to people from outside Ireland. It was good that I was an outsider but it was also good that I understood the Irish system. I hope that answers the question.
Cancer is a very discrete entity. It is a very large disease. After the cancer programme was well up and running, Dr. Barry White implemented what had been very successful clinical programmes around stroke, heart disease and a number of clinical programmes. Essentially, they were modelled in a similar way to the cancer initiative. In other words, they looked at best practice and decided where the complex care should occur. It has already been demonstrated that this type of evidence-based approach can work and deliver results. In many ways that does not require huge amounts of money. It means that national standards should be developed, ensuring that those standards are met.
If one has to bring resources to the table, bring them and then be sure that this standard of care is provided wherever one deems it will be provided.
One of the issues around all health care work, but particularly so in Ireland, is what I would call an attitude of "it if wasn't made here then it won't work". The problems of health care are the same pretty well in every country. There are issues around hospital beds, emergency room waiting times, access and having joined-up care. If there is a best practice model in Ireland, and I note that various groups have presented here already, it should be possible for a best practice model to emerge and then for that to become the national standard. What seems to happen here is that everybody argues that their hospital is different and, therefore, we end up with a hodgepodge of programmes and differences across hospitals. Coming from outside it is not hard to define what best practice looks like. If one gets a bunch of experts in a room they can probably define best practice for most acute diseases. I acknowledge it would be more difficult for some of the chronic diseases but it is not hard to do that. What has been missing is what I call a clinical governance model and an expectation that once best practice is defined, then that is what actually will happen. I believe physicians will support that move. This committee will probably recognise that in order to make change happen it cannot be 16 different models of health care for 16 different regions of the country. What one will have to look at is something that is fairly simple and straightforward. Ireland only has a population of 4.5 million people so it should be possible to define a single standard that will work everywhere.
Legislating that standards for the public and private sectors be the same is a no-brainer for me. There was not very much in the way of resistance.
On the issue of the centralisation of other oncology services, gynae-oncology was mentioned. I am not, quite honestly, up to speed on exactly how many centres provide gynaecologic oncology. Certainly, from my experience in Canada, there needs to be a critical mass and given the population here, the number of centres doing gynaecological oncology would probably be relatively few for the whole country.
In terms of delays in diagnosis and access to diagnostics, there is a particular issue in Ireland inasmuch as the diagnostic centre is highly hospital-focused although things are beginning to change. Clearly, to improve access to diagnostics, diagnostic facilities will have to be developed outside of the hospital sector, possibly attached to primary care facilities and there are pilot projects ongoing in that regard. Right now, Ireland is somewhat unique in the sense that one almost has to go to the hospital to get an MRI. One cannot get an MRI in the public system outside of the hospital system. That is something that can change and there will be significant issues around implementing that change but they are to be faced.
In terms of beds, there has been a dramatic shift in how beds are used in Ireland in the past decade. The amount of day surgery has risen by over 100%, as members will be aware. In Canada we still have the same issue that Ireland has grappled with. We have people in hospital beds who do not need to be in hospital beds. We need to find alternative models of care to free up beds. Finding more beds, and I had this argument with many people here, is not a solution to the problem. The problem lies in identifying who is in a bed, why is he or she there and why can he or she not be somewhere else. A considerable number of people who spend time in hospital beds in Ireland are there because there is nowhere else for them to go, and all the members are familiar with the problem. There are lots of ideas out there about how to address the problem and I am not going to comment on it here.
In the area of legislation, one thing I strongly suggest, and is hugely lacking in Ireland, is a legislated clinical governance model. Practically every day that I open The Irish Timesonline, I read about some other tragic case at the Medical Council of a doctor who was unable to diagnose or was clearly deficient in some area but had worked in two or three hospitals before somebody twigged to these facts. Why should it be at the level of the Medical Council that issues around competency are determined? There needs to be something at the level of the hospital where clinical governance ensures that the physicians or surgeons who work in a hospital meet a standard of care that is assessed and monitored locally. In Canada, I ran a department in Vancouver that had 50 specialists. Every year they had their appointment renewed based on their performance. There was no such thing as privileges to practice for life. Following appointment, one's performance was reviewed annually. If one was deficient in some way it was identified and remedial action was taken. We did not wait for that action to be such that when a patient suffered it ultimately was resolved at a higher level like the Medical Council. There is a real necessity in Ireland for clinical governance. There is lots of evidence available. Ireland needs a clinical governance model that looks at credentialing quality of care and monitoring care at a local level, and not coming from 30,000 ft. to determine how things are going to be.
Beyond that, replicating stuff across the board will work for well-defined clinical scenarios. The classical presentations for heart disease, chronic obstructive lung disease, asthma, etc. or for acute medical problems are well defined and their treatment pathways are well recognised internationally. There should be no real difficulty in saying what is the standard of care, it is a national standard and we will hold people to that standard. A lot of progress has been made through the clinical programmes of the HSE in some of those areas but it only points that that is the direction of travel. We need a national monitoring system to ensure that every hospital that is charged with a particular responsibility to provide a particular care model is doing what best care stipulates.
In terms of leadership, I was struck by the lack of clinical leadership in Ireland. In Vancouver and across Canada, clinician leadership is seen as being essential to make health care work. There is a stream and we have discussed it at the Towards 2026 forum with the college. There is a need to develop a clinical stream for physician leaders who are going to take leadership as part of their job and not as something off the corner of their desk that they do when they get home in the evening after a busy day in the clinic. My position in British Columbia before I came to Ireland was one where 100% of my position was to run the radiation and oncology programme for the entire province. I had little or no clinical responsibility but I was paid for that job. There will have to be an investment in training here and ultimately a career path. It is not enough to say, "Yes, we are going to have clinician leaders just do it off the corner of your desk." There are many incredibly competent physicians in Ireland and, on the same subject, there is a huge number of competent nurses who are grossly underutilised.
There are opportunities to develop clinical leadership and the results from other jurisdictions would encourage one to believe that such investment would be worthwhile. I think that covers all of the questions posed.
Professor Tom Keane:
That is an issue that the college is struggling with at the moment, namely, the generalist versus the specialist. Clearly in the management of many chronic diseases, the role of the generalist is still hugely important. The way health care has gone, unfortunately, is towards being further subdivided into smaller and smaller subsets. That might be okay for a city of 20 million people but for a country of 4.5 million there is a limit to the level of sub-specialisation that is possible to achieve, simply because the critical mass necessary to have a dedicated, world-class unit is simply not there. One needs a certain volume but the numbers in Ireland argue that the number of specialised units will undoubtedly be relatively few compared to other countries. One needs very large catchments for significant sub-specialisation to work. A one person unit run by a sub-specialist, no matter how brilliant, is ultimately going to fail.
I thank Professor Keane. I have been watching his career for many years.
I wish to refer back to some of the themes mentioned by the professor at the beginning of his contribution. He spoke about talking to people who know what the problem is and that is what this committee is all about. We are trying to identify the problem. In the professor's view, what is the problem and where should we start to change our health service? The second theme referred to by Professor Keane was building trust, especially between competing sections in the health service. Is logic and good data enough to convince people to change and to trust each other?
Professor Keane also referred to communication and communicating change. We have heard many witnesses over the past number of weeks suggesting that we orientate our health service in a different way, particularly towards community and primary care in the context of chronic disease management and changing demographics, which mean that we will have an increasing number of elderly patients. How would Professor Keane suggest that we go about reorientating our health service? I also seek his views on how we would better integrate primary and secondary care, which is one of the problems we have identified.
On the issue of the generalist versus the specialist, the only generalists left in the Irish health service are GPs and geriatricians. Everybody else is a specialist and as our population ages, we will have a huge amount of multi-morbidity which requires a holistic rather than a specialist approach. I ask for the professor's comments in that regard.
In thinking about the health system in Ireland I am reminded of the old yarn about the Kerry man who said, when asked by an American tourist for directions, "I wouldn't start from here". That is part of the problem. As my party colleague Deputy Billy Kelleher politely said, we have a complex health system. It is effectively dysfunctional but that is no reflection on the people working in it. Most of the people working in our health service are pulling their hair out with frustration at its dysfunctional nature. The nature of the dysfunction is part of the difficulty because we have silos, fiefdoms, localism and a lot of vested interests. Everybody can see that we need change and there seems to be relatively broad agreement on where we need to get to but nobody sees him or herself as the problem or even as part of the problem.
I am interested in the issue of change management. We met an IT specialist a couple of weeks ago and discussed the introduction of a new technology system for consultants. The consultants bought into that but the IT guys were given zero funding to effectively bring the consultants along, to train them up and explain why the system should be used. To bring about change in the health system we need buy in from the public and the trade unions. When we get that buy in from the trade unions, we need to bring the staff along with us to effectively implement that change. I am reminded of the scenario, for example, with cancer where we had the very political situation where people did not want to lose their local cancer units. A similar scenario arose with regard to mental health. The policy document, A Vision for Change, had broad support from the politicians, medical personnel and patients. Leaving aside the lack of full implementation, even the suggestion of the closure of certain units did not get public buy in. There was a trust issue at play there as well. I ask the professor to outline his views on and his experience of bringing both the staff and the public along in the context of change management.
I thank Professor Keane for his presentation this morning. There have been lots of developments in the treatment of cancer, particularly in our public hospitals and overall, the treatment here is very good. I am interested in the National Cancer Control Programme, NCCP, in the context of research. Are there any research programmes embedded in the NCCP itself or is that outside its remit? Obviously cancer research is very important. It is hard to believe that we have no cure for cancer with all of the money that is put into cancer research by various organisations globally, not to mention domestically. I ask Professor Keane for his views on that issue.
Professor Tom Keane:
There is a fair amount of repetition in those questions and I do not want to repeat myself about the management of change. I agree with Deputy Harty's point that there is broad general agreement on the direction. Certainly in the discussions we have been having about the policy out to 2026, there was broad agreement on the direction of travel towards the integration of primary and secondary care and linking up the systems. The committee will have the opportunity to have a briefing from that working group later in November. I am encouraged that there is a recognition that the status quodoes not work, essentially.
The issue around competing groups is based on a premise that if people compete there will be a winner and a loser. What needs to be shaped is a situation where everybody is a winner if we come up with the right solution. The media have a lot to answer for in this country in terms of the way in which health care is portrayed. Everything is profiled in terms of winners and losers. There has to be a new way of presenting information so that it is clear that the public is the winner if we come up with a solution that meets the needs of our population.
There is a huge lack of trust. The biggest lack of trust that I encountered here was between physicians; not necessarily between specialists themselves but between specialists and other groups of doctors. There were huge issues around the concept that if one doctor takes this then another doctor will lose that. There was always that sense of a winner and a loser. That is something that needs to be brought out and debated because the losers in this whole system are the patients. All health care systems tend to be very provider focused. It is one thing to mouth the words about being patient focused but ultimately, that is what the system must be. As long as the system is provider focused and dominated by the interests of the constituencies within the system we will have a problem. This is not unique to Ireland. In most health care systems the providers, while mouthing the fact that they have the public interest at heart, are very often simply protecting their own turf. There needs to be a debate on the fact that there are no winners and losers within the system. The system has to work for people.
There cannot be enough communication. I have said previously that there were weeks when I was unable to talk when I went home because I was so hoarse from talking. Communication on its own is a tool for building trust, but it must be accompanied by transparency, integrity and a willingness to listen. Some of the best ideas for improving health care come from the people who are working at the coalface. Time and time again, it is those who work at the front line who actually understand what the problem is. There is a way to engage people at that level. I have to say that a cynicism has built up within the health care system. Somebody referred to it as "report fatigue". People are tired of reports and they want to see action. I think there needs to be an iterative process. I do not believe the problems in the health care system in Ireland are too big to fix. They can be fixed. As part of the public debate, it will be necessary to make it clear that if we want a health care system that is comparable to the systems in the Scandinavian countries, we will have to pay for it. Countries with large and relatively good health care systems that meet the needs of their populations generally have higher rate levels of taxation. In other words, what one gets is what one spends.
The issue of change management could not be more important. I have been involved in major change in three jurisdictions. The first thing that needs to be done is to put in place an overall change management structure. This means making an investment in the business of managing change. We cannot manage change by telling people "we have had a great idea, it is fully evidence-based and we are starting on Monday". We need to engage in a way that makes the people who are going to be involved in change part of the solution. We cannot simply hand them a top-down plan and expect it to work. The silo functionality that Deputy James Browne mentioned is a problem that can be addressed. There may be issues around the funding model that can address that. We tend to build silos when we compartmentalise funding. Everybody tries to protect his or her piece of the pie. My view on the integration of hospitals and communities is that there must be a mechanism that enables hospital care and the care that occurs outside the hospital to be funded from a single envelope. It should not be the case that the hospital gets its money and community care is funded separately. There are some huge disproportions in funding allocations. The funding needs to follow where the system wants to go. We cannot drive the system if the funding model does not support it. That is a considerable piece of work.
I was also asked about getting buy-in from the public and bringing the patient along. I think that is part of the change management issue in Ireland. I had an excellent press officer, Ann McCloon, when I was here. She taught me so much about how to manage the Irish media. We refused to engage in 30-second soundbites. We let it be known to most of the major media outlets that we were prepared to engage in indepth conversations about the future of the system, but we did not want to give 30-second soundbites. That was difficult because the media basically wants a quick story and a quick angle. There needs to be dialogue with the public, but the complicated nature of health care means that these issues cannot be dealt with in a 30-second soundbite. There is a need to find a mechanism to facilitate engagement at local and regional levels. I am sure the committee has heard suggestions around how to engage communities. I am in favour of locally delivered services as long as there is overall national oversight to ensure every region does not deliver the service differently. I think there is a huge need to engage with the public at local and regional levels. People need to be part of the change, rather than simply sitting on the outside and acting as advocates.
Deputy Madigan asked about research. To my disappointment, the national cancer control programme has no mandate for research. I had to make a pragmatic decision. The lack of such a mandate is most unusual because research is part of the mandate of national cancer programmes in most developed countries. I chose to leave it aside at the time because there were many other burning platforms. I believe that down the road, the embedding of cancer research within the cancer programme will have to be a key component of the national cancer programme. This ultimately becomes a major issue when we are trying to attract and recruit world-class individuals. If they are coming into an environment where there is no research support, it is likely that they will go elsewhere.
I thank Professor Keane. I would like to ask a few questions before we finish up. Practically every group that comes before this committee mentions access to diagnostics. I think the point about access to diagnostics outside the hospital system was well made. We are taking that on board. We hear a great deal about the importance of integration of services. To what extent has Professor Keane found that the organisational structures within the HSE have impeded that integration?
My second question relates to this country's two-tier system. Deputy Billy Kelleher spoke earlier about the lack of consistency in access to care, particularly for public patients. This big emerging problem is being raised by many of the groups that are coming before us. How did Professor Keane deal with that in terms of rolling out a programme? How did he manage the entitlement of those with private health insurance cover to quicker access to care?
Professor Keane referred to the need for legislation in a number of areas. I particularly noted what he said about the need for legislation to cover clinical governance. Does he feel we need legislation to deal with the issue of entitlement to access to care? This question relates to my previous question about the two-tier system.
Professor Keane spoke about the importance of having a good and robust strategy to start with, and then having an implementation plan. What about the monitoring element of that? Where is the oversight or monitoring of the implementation of the cancer programme?
Professor Tom Keane:
I do not know how well I can answer the Chairman's questions. I am shocked to recall that nine years have passed since I sat in this room, or some similar room, to be questioned at length by Senator James Reilly and a number of other individuals about what I was trying to do for cancer. In light of my lack of up-to-date knowledge on how well the HSE is doing with the integration of services, I do not think it would be fair of me to comment. I know it has been pushing hard to develop integration. There have been some good examples. I understand the committee has heard from the Carlow-Kilkenny group. I do not doubt that there are other such examples. While it would be unfair of me to state any current view, I will say that I think the HSE is signalling seriously that it is working very hard in this area.
The Chair also asked whether I believe legislation is necessary to deal with the issue of entitlement under the two-tier system. I have never worked in private health care. In Canada, public health care is accessed by 99% of the population. The 1% who do not access public health care have to go to the US to get private health care because it is not available in Canada. That is covered under the Canada Health Act, which is the most popular piece of legislation with the Canadian public. They treasure it. It is iconic. If one asks Canadian people what distinguishes Canadians from Americans, 80% of them will say it is the existence of publicly funded health care.
The health care system is something in which Canadians take pride, although I am not for a minute saying it is not without problems. Canada has a publicly-funded system and it has many significant issues, a number of which resonate here. However, it is a single-tier system based on the premise that a co-existent private system ultimately will bleed away resources and expertise from the public sector. The issue is being tested in the Supreme Court of Canada this year as some physicians are taking the Government to the Supreme Court to appeal the legislation that prevents physicians from seeking additional funds for privately offered care. This matter, which is covered under legislation, has been highly controversial but publicly-funded health care was introduced in Canada in the late 1930s. The predecessor of the National Democratic Party, NDP, Government, which was a labour movement, brought publicly-funded health care to Canada in the 1930s and 1940s. Since it has been in place, it is the only thing the public generally agree that the government does right.
While I obviously have a bias in favour of publicly-funded health care, if one looks back at the cancer programme, the vast majority of patients in Ireland are getting their cancer care in the public system, far more than for other non-cancer diseases. One of the reasons for this was that we were able to assure people that their access and quality of care in the public system were good. If one provides all of the key features that people are looking for in the public system, there is no reason for a private system to exist. If people are to pay out of pocket for private care, there must be an underlying premise that somehow they believe they are buying something extra and better than what is available in the public system. Until that belief disappears, one will have people hanging onto privately-funded care. I understand approximately 45% of people in Ireland now have private insurance so it is a big mountain to climb.
In terms of monitoring, the cancer programme has key performance indicators. While I am not up to speed on all of them, many dozens of performance indicators are published by the programme either every month or every three months and if the programme is not meeting certain performance indicators, the issue is addressed immediately. There is also a fair amount of competition between the cancer centres to be seen to be the best performing. This is very healthy because it means they want to be able to state, for example, that 90% of patients will be seen within two weeks. Undoubtedly, the rapid access clinics that were instituted by the cancer programme for prostate, breast and lung cancer have provided a level of access that is totally satisfactory and comparable with any publicly-funded system in the world. There is no reason this could not exist elsewhere in the system.
I do not believe the problems of the Irish health care system are too big to fix. They can be fixed but what is required is political will, which comes back to the committee, and education of the public to enable people to understand the issues in order that they could be persuaded to pay more in taxes to fund health care compared with some other alternative if asked to do so. I am not pessimistic in this regard. An iterative approach is needed, one which demonstrates that this can be achieved through a number of steps. Trying to take on system change across the whole system at once is unlikely to be successful. A strategy that is iterative, extends over five or ten years, identifies a number of milestones and takes each one of these in sequence is the way to build trust.
I thank Professor Keane for his contribution and for being so generous with his time. We very much appreciate him sharing his experience and expertise with us and the frank manner in which he responded to questions.