RCSI head: ‘Every health service workaround takes time away from patient care’

The President of the Royal College of Surgeons in Ireland (RCSI), Prof Deborah McNamara, is very aware of the “considerable challenges” facing newly qualified surgeons.
The health service is a very busy sector, she says, that places enormous demands on those who work in it.
“The infrastructure in lots of areas is not as good as it could be, and it’s very easy for young surgeons to be isolated when they start clinical practice,” says Prof McNamara. “There are a lot of demands placed on them, and the public have an expectation of very high standards of care.”
Sometimes this can be delivered, she says, although she admits that, at other times, “it can be difficult to deliver the high standards of care that you would want to”.
In her first interview since her election as president in June, Prof McNamara, a consultant general and colorectal surgeon at Beaumont Hospital in Dublin, identifies the challenges ahead.
Although the health service is undergoing a significant organisational and technological transformation, some elements remain largely unchanged, one being infrastructure. This situation, she says, can “slow the pace of progress”.
“Many of our operating theatres were designed and built decades ago, and they were built before innovations like laparoscopy or robotic surgery were even imagined,” she says. “There is a mismatch there between the services that surgeons can deliver and the ones that are enabled by the health service in which they’re working.”
Many staff have to think outside the box to counteract such difficulties; Prof McNamara says workarounds have become “a characteristic” of the health service.
[  Ireland’s health system is one of the lowest performing in the northern hemisphereOpens in new window ]
“Health staff generally work really hard to deliver the best care that is possible for a patient, and the less the infrastructure and systems support that, the more effort and energy health staff spend delivering workarounds as opposed to delivering care”.
This is particularly the case in the area of IT, she says, due to largely paper-based systems leading to “duplication of effort” and “every workaround taking time away from patient care”.
However, efforts to change this are under way; the Government recently published its digital framework, for example, which would see the introduction of electronic patient health records, and the roll-out of a patient app by the end of the year.
Health service staffing is another topic that constantly arises. Unions say there still is not enough, while the Department of Health says the workforce has grown significantly in the past four years.
However, there is an ongoing recruitment challenge, with many recently qualified doctors emigrating for a number of years, particularly to Australia. There can be push factors for younger doctors to work abroad, Prof McNamara says, as “medicine is a 24 hour profession”.
“Paradoxically, sometimes the things that are designed to make things better for trainees can also have unanticipated consequences,” she explains.
“It’s very desirable to shorten the length of a shift, but the whole weekend still has to be covered, so you might end up working more weekends instead of less weekends if you work one shift per weekend.”
Time spent working abroad can be a good thing for the State. Higher surgical trainees, for example, tend to complete a one- or two-year international surgical fellowship after their programme in Ireland.
“They travel abroad, work in a bigger centre, usually in some place with a bigger population, and really just develop their expertise in a small area, often an area [in which] you need to be in a country with a big population to see a sufficient volume of cases in,” she says.
“That’s actually really enhanced our health service over the years, because the majority of surgeons who go abroad for training, at the end of their training actually come home and practice as consultant surgeons.” The most recent data, from the 2019 class, found 80 per cent returned to Ireland, she adds.
There is also the reverse, with more than 60 per cent of RCSI’s student population being international students. Those who come from within the European Union can work in Ireland after obtaining their qualification if they so choose. For those from outside the bloc, however, the rules are different.
“Some doctors who qualify in Ireland, and who we know have met the standards of Irish medicine, because of employment legislation don’t have the option to practice in Ireland,” she says.
[ Almost 40% of doctors working in Ireland last year had qualified overseas, says medical councilOpens in new window ]
“Legislation is way beyond my pay grade but, definitely, if we have Irish graduates, we know they’ve met the standards that are required in Ireland to practice in healthcare. It stands to reason to me that they’d be real assets to our health service. Often, they’re some of the highest-achieving doctors in a qualifying year, and yet we can’t retain them in our health service.”
At the same time, she says, in the later stages of their healthcare careers, Ireland is “importing doctors from other countries, where they have studied in a language other than English”.
“And so it seems strange that we’re training and educating international doctors who would really [be a benefit]. For those doctors that do want to work here, you know, it is unfortunate that there isn’t a way that they can do so.”
The State’s population is increasing, as well as becoming older and more diverse, which all changes the needs and demands on the health service. Emergency department overcrowding is at unsustainable levels, while waiting lists – though decreasing – remain above 700,000, with more than two-thirds waiting longer than target times.
One thing that can be overlooked in this situation is “sometimes it’s not as obvious that a patient on a waiting list is as at risk as a patient in an emergency department”.
“We’ve been very passionate as a college and as individual surgeons to make sure that there’s equal priority to the patient who’s on a waiting list, waiting for care, because they’re not as visible, and the risks that they’re facing are not as visible to the health service, but they’re equally important,” says Prof McNamara.
[ It’s not quite Grey’s Anatomy but a career in medicine can be very rewardingOpens in new window ]
In light of this, she believes there is a need to think about the “separation of emergency and scheduled care”.
The development of surgical hubs, for example, is being done “really efficiently”, and they’re going to be a “really important part of the solution”.
“But they are focusing on ambulatory [outpatient] surgery. So they’re focusing on lower-complexity work. But the hubs focus only on the ambulatory part of the waiting list, and so patients who need the services of bigger hospitals or specialist care, they [the hubs] aren’t going to address that part of it.
There tends to be a “variation across the year”, she says, in terms of elective surgeries being completed. Higher emergency presentations to hospitals during the winter period can result in cancellation of elective or scheduled procedures.
“Until we have that [separation], it’s very hard to see how you can get rid of that variation, unless you have a very substantial increase in infrastructure.”
Right now, she says, “we try to do everything, every place, and that creates demands everywhere”.
“We have very few hospitals in Ireland that focus on elective surgery or scheduled surgery. We know that the ones that do focus on scheduled surgery can do it really well,” she says.
“So it is possible to separate scheduled and emergency care, but it does require action, and it requires what can sometimes be hard decisions.”