The new chief medical officer is adamant that cutbacks will not scupper patient safety reforms, writes DR MUIRIS HOUSTON
There was little surprise at the recent appointment of Dr Tony Holohan as chief medical officer (CMO) in the Department of Health. As deputy CMO, he had become the public face of the department, sent out by the Minister for Health, Mary Harney, to do battle on Prime Time and TV news bulletins during various cancer scandals. Within days of taking up his new post, he again featured prominently in last December’s dioxin food scare.
Not that he was a shoo-in for the post: he beat off significant international competition. But as one of the prime architects of the successful national cancer strategy and of the primary care strategy, his media skills were probably the icing on the cake for the appointment panel.
His appointment coincided with a significant change in the powers and responsibility of the office holder. For the first time, the CMO has executive responsibility in two areas: patient safety and quality; and health promotion and public health. Until now, the office of the CMO operated in a purely advisory capacity within the department – a role that continues for other policy areas – but for patient safety and public health it is up to Holohan to deliver specific reforms.
A 1991 medical graduate of University College Dublin, who subsequently trained as a specialist in both general practice and public health medicine, Holohan agrees that the Michael Neary scandal in Drogheda “was on par with the Bristol Heart Inquiry” in Britain as a turning point for the Republic’s health service.
While acknowledging that prevention of error does not mean a zero occurrence of healthcare mistakes, he says there has already been significant change, citing the legal protection of whistleblowers and the inclusion of clinical audit in the new consultant contract.
As chairman of the implementation process for the patient safety commission report, he wants to see all 134 recommendations “set in train” within 18 months.
Holohan cites Susie Long – the Kilkenny woman who died of bowel cancer after she languished on a waiting list for colonoscopy – as the case that triggered serious questions about cancer care here. And he focuses on an unexpected target when asked about the fallout from the breast cancer scandals: “Medics have encouraged people to develop a sense of infallibility in their decision making . . . there is no such thing as the ‘all clear’ from any medical test and we need to improve the public’s understanding of this.”
So what would happen now, under his regime, if a letter arrived in the department from a hospital consultant detailing specific patient safety concerns? “There are new procedures in place in the HSE, Hiqa and here . . . the letter won’t be filed away – I’m now personally responsible for it . . . it won’t be just a question of sending it to the HSE with a sense of ‘that’s great, it’s off my desk’.”
He is adamant that – however long it takes to deal with an issue – a letter like this will continue to come back on his agenda.
And what about an extreme safety event, has he the power to move quickly and close down a malfunctioning unit within a hospital?
“I don’t feel in any way inhibited from dealing with – even one involving private hospitals,” Holohan says.
He hopes to bring an airline pilot on board the patient safety implementation group in the belief that health has much to learn from aviation safety (see panel). And he is adamant that mounting economic pressures and health service cutbacks will not scupper patient safety reforms. “Health system efficiency and patient safety are one and the same . . . I completely reject that we need extra money . . . Historically one of the reasons we have not been able to get past first base is there has been a sense that the change process poses a risk to the safety of patients.”
He firmly believes that primary care can take over from hospitals to the extent that Prof Bernard Drumm, chief executive of the HSE, says it can. And he feels that having general practitioners as gatekeepers to the health system is important – and not just for cost-control reasons. “The health system can be difficult to understand and it probably works better if patients can be guided through secondary care by their family doctor.”
The new CMO was a hospital patient just once. In the 1980s, playing soccer for the UCD pre- meds team, he sustained a complicated fracture of his lower leg. Perhaps his most significant memory was waiting an entire week for the surgery to insert pins and a plate to repair the damage. The operation was repeatedly postponed because of operating theatre pressures.
This was the time of the last major recessionary cutbacks to Ireland’s health service – let’s hope Holohan won’t be dealing with the consequences of a similar bottleneck in our hospital system in these difficult times.
Piloting new procedures: banning egos from hospital theatres
If Tony Holohan’s plans come to fruition, your next hospital operation could be carried out by surgeons and nurses working to procedures currently used by airline pilots.
As part of his mission to improve patient safety, about 10 days ago the new chief medical officer (CMO) spent some hours on the flight deck of an Airbus A320 as it flew from Dublin to Manchester and back.
What he saw from the jump seat in the cockpit amazed him.
"The captain and co-pilot introduced themselves to each other before the flight. It was the first time they had flown together, but because the whole thing is driven by standard operating procedures [SOPS], it was not a problem."
Holohan was struck by the constant communication and teamwork, not just between the pilots but also with cabin and ground crew.
He also noted the ease with which the captain and first officer exchanged roles, depending on who was flying the sector.
"The cockpit resource management and procedures apply to almost everything – it defines authority and the extent of it."
The CMO sees this approach as the key to improved patient safety.
"SOPS can be applied to the operating theatre or to the community care of the person with diabetes – the principles are the same."
The argument that aviation can help improve medical safety is not a new one.
Some years ago an Irish hospital consultant and former airline pilot wrote: "The shared responsibility on the flight deck ensures that the first officer has a major input into the function and decisions of the flight and can forcefully direct the captain without recrimination back at base. The same scenario in medicine would generate an exit, stage left."
A study published in the British Medical Journal in 2000 compared how surgeons and nurses dealt with error and teamwork compared with pilots. It revealed that cockpit crews advocated flat hierarchies but surgeons were less likely to do so.
Medical staff said error was important but difficult to discuss in their hospitals. Crucially, medical staff denied the effects of stress and fatigue on professional performance.
More recently, research carried out for the World Health Organisation has shown that adopting a more focused and process-driven approach to surgery helps reduce error rates.
Holohan is on the right track: the question now is how long before we see egos banned from hospital theatres.