‘There’s good practice and appalling practice’ in health service, says outgoing Hiqa chief

After eight years running a rule over the Irish health service, the head of the State’s health watchdog has some good things to say about the system.

“We’ve got some very good pockets, some phenomenally experienced people, a capable and skilled workforce on the whole and some appetite for innovation.”

That, however, is about as good as it gets. The Health Information and Quality Authority (Hiqa) has been called in to too many disasters in the Irish health service for outgoing chief executive Tracey Cooper not to be aware of its shortcomings.

While she believes the system "is in a better place now than it was a few years ago" she tells The Irish Times this progress needs to be sustained.

Every health system makes mistakes but Cooper says the key challenges for the Irish health service are to learn from its mistakes and to ensure there is accountability on the part of those responsible.

In other countries, support is given to people having difficulty doing their job. “It’s a serious business, healthcare. If you’re having persistent problems and you’re not able to do that role, something should happen.”

“If you’re a consultant, you should be supported to do a different role. If you’re a manager accountable for services and you’re not able to do that job, then you shouldn’t stay in it.”

There is too much emphasis on the technical aspects of providing healthcare and not enough on the need to modernise the focus around "the humanity, the dignity, the communication and empathy with the patient," she says. And when things go wrong, the quality of response varies greatly. "There's good practice, and there's appalling practice – and that's inexcusable."

Trenchant criticism

Asked whether Ireland has a safe health service, the Welsh woman says it is “difficult to say” because of a lack of the kind of data collected in other countries. “I think we provide really good services in some areas and in other areas we’re not quite sure because we don’t have the data.”

“I wouldn’t say we were the safest. We still have quite a long way to go.”

Hiqa's trenchant criticism of safety standards in small hospitals has led to the closure of many emergency departments, often in the teeth of local opposition. But Cooper says it's not just about the emergency department. "It's about the totality of services a hospital can safely provide that support what an emergency department is or isn't. If there aren't sufficiently qualified people to treat what you're admitted for, you're in the wrong place."

Groundbreaking report

Hiqa got off to a flying start back in 2006, as Cooper recalls. “I remember the first challenge very well. We were five days after being established and I got a call from [

then HSE boss] Brendan Drumm saying will we do an investigation into Rebecca O'Malley's cancer misdiagnosis case.

“We had no staff, but the answer was yes. Everyone was watching – how long would it take, would we ever publish it? But it was also an opportunity to lay our cards out on the table, to say this is how we are going to do business.”

The result was a groundbreaking report which paved the way for the modernisation of cancer services and, ultimately, saved many women’s lives.

The authority has followed a similar approach since by aiming for “the maximum ripple effect” for its work. “The challenges didn’t come from tragic incidents that trigger us to do something, the real challenges come when we’re writing a report and making recommendations, and we have to get it right for the benefit of the wider population.”

In this vein, a report into the shortcomings of Ennis Hospital carried recommendations applicable to all smaller hospitals. When the system was slow to implement these findings, Hiqa drove home the message in a follow-up report on Mallow hospital two years later.

The recommendations in another report on Tallaght hospital were pitched deliberately to transform governance in all hospitals. “It’s never just about one event, albeit tragic,” says Cooper. “It’s about the wider recommendations and then coming back later to ensure they are implemented.”

Despite the contracting economy, the authority has grown as new work is put its way – the regulation of nursing homes and care centres, special investigations into maternity services and the ambulance service. It currently has 170 staff and a €15 million annual budget.

Cooper says she “doesn’t do highlights” but she is clearly proud of the improvement in breast cancer services that followed its work in that area, as well as the authority’s work in monitoring standards in nursing homes.

But she knows the information available to patients remains uneven; consumers know whether staff in a particular hospital wash their hands, thanks to Hiqa reports, but in general they know little about the quality of services in the hospital, and how it compares to other facilities.

Cooper acknowledges the deficit of information. This should change soon, because the authority has drawn up standards against which to measure the performance of hospitals.

'Layer of bureaucracy'

The agency has its critics. Oncologist and Senator John Crown, says its "another layer of bureaucracy" delivering "highly spun reports".

“Everybody is entitled to their own opinion,” she responds. “We’re not the kind of country whereby people who provide services can demonstrate how good they are in terms of performance, outcomes and safety. They’re not making this information publicly available.”