leo varadkar – A Medical Education

With his recent elevation to Taoiseach, something Leo Varadkar (who was supposed to work with me when I did a locum in Tallaght in May 2007… but he was occupied with some election or other) said in the late 1990s got a fair bit of coverage. This was to the effect that as a doctor you can help a few people, but as Minister for Health you can help millions. While at first glance this seems like a truism, it has for some reason got under my skin. There are various reasons for this, not all of which I will get into. Perhaps I am jealous of a road not travelled! (I am pretty confident I am not)

In a way it sums up a particular seduction – the seduction of the World of Policy. Get interested in any field – from the natural world to technology to medicine indeed – and sooner or later the siren song of policy will be heard. Wouldn’t it be great to Make A Difference not just on the piecemeal, day-to-day way, but on a grander scale? Increasingly I think not. Clearly someone needs to formulate policy and to think about things on a broad scale – but they should do so without illusions and with a certain humility. People have a habit of behaving in a way that the enlightened policy makers don’t foresee. The circuit of conferences and “networking” can become an echo chamber of self congratulation. Doing good, perhaps, is best done on a smaller scale.

These thoughts are occasioned by reading about the Salzburg Statement. This is something I heartily approve of – a call for action to ensure all children enjoy the right to play in a nature rich space within ten minutes of their home. The statement is made up of eight key actions:

Eight actions to transform cities for children

Ensure children of all ages, backgrounds, income, and abilities have equitable access to nature and play regularly and in meaningful ways to promote good health and wellbeing.
Embed nature in everyday places used by children, such as schools, backyards, parks, playgrounds and city streets, to make the city into a natural outdoor classroom.
Involve children in designing and planning natural spaces for recreation, education, inspiration and health, to give them ownership and pride in their local communities, schools and parks
Build curiosity, wonder, and care for nature in children (for example by greening school grounds and involving children with community gardens).
Protect natural features across cityscapes and create an equitably distributed network of accessible green and nature-rich spaces that all generations can reach on foot.
Connect cities with the broader ecosystems in which they are embedded, creating corridors for people, plants and animals to move safely across the city and into its surroundings.
Establish more urban conservation areas to increase access to nature and connect cities to the broader protected area network.
Work together through cross sectoral and multi-level partnerships to build an inclusive culture of health in cities.

There’s nothing there I would disagree with, though as with all these kind of interventions I would like more robust dissection of what, say, Item 3 would mean in practice.

I am always a little wary of dressing up worthy activity in the mantle of Health. What Resting a case for nature on the vagaries of purported health benefits can be a dangerous and debunkable game – especially with the media. This visual handily shows how media can seize on single studies to generate headlines:

One can easily imagine a Katie Hopkins-ish journalist seizing on the inevitable ambiguities of research to “debunk” the claims for health benefits of nature.

I should state very clearly I have no reason to think that the Salzburg Statement is a wonderful initiative I look forward to hearing more of. But I am a little wary of the siren call of the World of Policy.

Another excellent blog post on the ARCH website, this time by Dr Marcella McGovern, on the blame culture of the Irish health system. The trigger for this article was the recent controversy on “hidden waiting lists.” This led to a rather predictable response from the current Minister for Health:

The Minister for Health, Simon Harris, responded to this programme by saying that he “intends to shine a light” on management in the Irish Health Service Executive (HSE) and that if management does not “measure up”, they will be removed from their roles.

Tough talk, but as Dr McGovern writes:

it fails to acknowledge the Government’s responsibility for that problem. Governance, performance oversight and holding the HSE to account for the implementation of national health policy are key functions that the Minister for Health and his Department are responsible for performing on an ongoing basis; not in response to a crisis. The question put to Ministers for Health in a crisis therefore, should be where in your Department’s oversight of the HSE did you fail to detect this problem and what steps are you taking to correct the problem and ensure that it doesn’t happen again?

Of course, this is hardly new:

Paul Cullen highlighted in an analysis piece in the Irish Times (Irish Times, 11^th February 2017) that Minister Harris’ predecessor, Leo Varadkar, similarly promised that “heads will roll” over hospital overcrowding. Yet, this winter again saw overcrowded Accident & Emergency Departments resulting in planned inpatient and outpatient appointments being postponed. The back-log of these postponed appointments are now contributing to the current crisis over long waiting lists, illustrating that unjustifiably “blaming the bureaucrats” (Dubnick, 1996) has knock on effects.

Dr McGovern uses the work of Dubnick on “prejudical blame culture” as a framework for her piece:

Three major conditions (for defining prejudical blame culture):
1. It makes no requirement that the blamed person or collection of persons have assumed responsibility for the condition they are blamed for; rather, it targets an ill-defined but inclusive group that everyone knows to exist (e.g. bureaucrats);

2. It doesn’t require any role for the blamed in contributing to the cause of the blameworthy or harmful condition. It is assumed that the vaguely defined ‘they’ are highly influential in shaping the world;

3. [It] eliminates the need for any degree of specificity regarding what the harmful condition entails. It could be the decline of the economy, or the loss of national prestige, or the general malaise of society. (Dubnick, 1996: 22).

Dr McGovern’s work, in the ARCH context, is on the effect on system readiness for innovation. Of course, blame culture has a much wider impact, paralysing innovations beyond the technological sphere:

From a Connected Health perspective, there is a danger that a blame culture demonstrated at the highest levels of the Irish health system will have a trickle-down effect, compromising system readiness for innovation. If the Department of Health blame the HSE for poor management and the HSE blame the Department of Health for inadequate resources, and if clinicians blame managers for excessive bureaucracy and managers blame clinicians for resisting change; organisational trust may be lost in the battles between “us” and “them” (Firth-Cozen, 2004). Within such environments, potentially transformative leaders and early adopters behave cautiously and become reluctant to take “ownership” of innovations (Heitmueller et al. 2016), which by their nature carry the risk of failure and unintended consequences (Ash et al. 2004).