Irish Medical Organisation

IMO President's Inaugural Address - Dr. Paul McKeown

14th April 2012

Text of Dr Paul McKeown's Presidential Address  to the IMO AGM 2012
Chief Executive, Honourable Past Presidents, Fellow Members, Ladies and Gentlemen,
I am delighted and honoured to address you this evening as President. 
On emerging, in 1984, from University College Dublin, as a freshly-minted medical practitioner, cloaked in my crisply-starched white coat and garlanded with the instruments of my trade, one of my first acts (before even sorting out my intern jobs in Dr Steevens’ Hospital) was proudly to upgrade my Irish Medical OrganisationStudent subscription to that of a newly appointed medical practitioner. My medical diplomas, my stethoscope and my bleep along with my certificates of membership of the Medical Defence Union and the IMO marked me out, in my eyes, as a real doctor.  A young consultant, with whom I began my internship summed up (and only partly in jest) the distinction between these two certificates; the purpose of your Medical Defence Union subscriptions, he said, “are to protect you from your patients; your IMO subscriptions, on the other hand”, he insisted, “are intended to protect you from your Senior Colleagues”.  Even at that very early stage, I realised that the IMO had a much wider and deeper role than merely “protecting me from my Senior Colleagues”.  
In 1890, the Original Articles of the Irish Medical Association (which had been in existence since 1839) included such elements as:
The formation of a body “competent to exercise influence in Sanitary and Medical Affairs for the Public Benefit”
the promotion and protection of “the interest of the Medical Profession”
Watching “the proceedings of Parliament upon matters affecting the interests of the Medical Profession”
A process to enable the Association to “inform the members ….[on] all matters affecting the interests of the Profession ...[affording them the] opportunity of expressing …. opinions and offering …. suggestions”
These aims are still evident in the IMO's Mission Statement today in which the Organisation’s role is to “represent doctors” while being “committed to the development of a caring, efficient and effective Health Service”, ensuring that our patients remain our priority.
It has been this combination of a professional medical association with trade union representation rights that has always appealed to me, particularly as a Public Health Physician.  Like its sister organisation in the UK, the British Medical Association, the IMO is geared to the professional and personal needs of its members while acting as an advocate for our patients, most particularly those with the weakest voices and who are the most marginalised in our society.  In his treatise on Utilitarianism, A Fragment on Government, Jeremy Bentham stated that,“It is the greatest happiness to the greatest number that is the measure of right and wrong”.   It was just such a sentiment that first attracted me to Public Health, I having, in my mind, an idea that I could assist people at a population level.  The focus of the IMO is very much on bringing about change at a population level, and for me the IMO has always been a Public Health organisation.
Doctors occupy a unique position in the minds of people.  Year after year, doctors head polls of the most trustworthy professionals.  The most recent such Irish poll, carried out on behalf of the Medical Council last April, found that 88% of respondents trusted doctors; ahead ofProfessors, Teachers, Gardaí, and Scientists, and far ahead, alas, of Politicians. A similar Ipsos/MORI poll at the same time in the UK, found that doctors were also the most trusted profession (again 88% of respondents trusting doctors). Moreover, despite the very high prevalence of private practice in the US, doctors have consistently come close to, if not at the top of, equivalent American polls.  Research has identified doctors as being one of the most likely professionals to which a women would divulge having been raped or to whom parents would bring their concerns about the possible abuse of one of their children; in other words, subjects invested in such intensity and pain that those confiding feel at their most vulnerable and frightened.
Much research has been directed towards determining “What makes a good doctor?”The factors most frequently reported include: compassion, honesty, competence, commitment, empathy, respect, creativity, open-mindedness, a capacity to listen and a sense of justice.   A pretty tall order.Respondents in these studies feel that doctors should be good “human beings”, and that a good doctor is one who naturally empathises with,and has a genuine desire to helpothers.  In addition, most people see doctors as special individuals to whom others look, as leaders who will take extra efforts to protect and assist their patients.  
A recurring theme in many such surveys is that respondents feel that the pendulum has swung too far towards science and away from the humanitarian aspects of medicine, there being too great an emphasis on high technology diagnostics and insufficient clinical examination, particularly history taking - that most human part of the doctor-patient relationship
When respondents were asked about 'bad doctors' they mentioned characteristics such as an inability or unwillingness to listen, impatience, unwillingness to admit to mistakes, and aloofness.  A significant proportion of patients felt that bad or underperforming doctors were the product of a society that undervalues doctors yet expects, and is unwilling to accept anything short of, perfection.The workload placed upon modern doctors meant that it was difficult to devote sufficient time to listen to and empathise with their patients.  To me this says that patients want to be closer to their doctors than they already are; that they want a deepening of the doctor-patient relationship.
We doctors are rightfully proud of the quality of service we consistently provide for our patients.  But given the taxing times in which we live, maintaining the quality of that service is, and will become, increasingly challenging.  
As a result of political improvidence, poor management and a deluded belief that we were in a period of plenty that could never end, we have arrived at a situation where we have ceded a considerable amount of economic, and as a result, political, social and even legal, sovereignty to others. 
During the “Tiger” years, the massive increase in public expenditure did not translate into a proportionate increase in the quantity or volume of our public services.  In health, there was massive reorganisation but without an equivalent improvement in the efficiency of running the Service.
However, since Ireland entered the EU/IMF Programme, public spending has been comprehensively and colossally reduced; €15 billion between 2011 and 2015;  €2.5 billion of this coming from the Health budget. 
Despite the significant, earlier, increase in spending, Ireland’s health expenditure waslow by international comparison.  In 2009, Ireland’s total health expenditure as a percentage of GDP was 9.5%, placing us 18th overall in terms of health expenditure out of the 34 countries that are members of the Organisation for Economic Co-operation and Development (OECD).  This is less than the health-spend of countries such as the US, Norway, France, Sweden, the UK, Spain or Germany.  Since the recent economic contraction this figure will have fallen even farther.  
This reduction in current public spending has had the effect of reducing the funding necessary to ensure that the health service is run in an effective and high quality manner. The health system is a finely woven mesh, each part highly dependent on all others around it.  A delay or reduction in one area will be transmitted along the mesh, multiplying and amplifying in the process.  
Reduced funding leads to a reduction in the numbers of front-line medical staff and, significantly, in the support staff necessary to ensure that front-line staff are freed up to concentrate solely on medical activities rather than being diverted into administrative and other support work actions – work that is necessary but deflects and distracts from direct patient care. 
In Emergency Departments, medical staff shortages lead to lengthening waiting lists, staff constantly having to triage and prioritise beyond what is normal.
In Hospitals, staff shortages lead to fewer doctors to assess patients, and to staff operating theatres, and other vital centres.  Nurses accompanying patients on trips to specialist centres for investigative procedures, leads to even greater slowing of throughput, meaning that the system is constantly in “crisis mode“.
In community settings, staff cannot cope due to manpower and resource shortages leading to increased admissionshospital.  In addition, the increasing demands on quality provision and audit also eat into staff time, meaning that performance monitoring (although important and necessary),can paradoxically erode quality.
In Departments of Public Health, staff shortages meanfewer physicians, scientists and nurses.   As GPs, Hospital Consultants and Laboratory Directors report cases of notifiable diseases, there are fewer available staff to ensure that all necessary control measures, for example in the case of disease outbreaks,are in place to protect the public’s health (especially the most vulnerable suchas small children, pregnant women and the elderly). Vaccination and child health services suffer as a consequence.  All these reductions are having drastic effects on Public Health, especially in relation to infectious disease, since effects are seen quickly due to their short lead in time.
In the 1980's a cut in funding for Public Health Services in New York City led to a resurgence of tuberculosis, many of which were drug resistant forms.  It is estimated, as a result of funding cuts, that New York saw 20,000 excess cases of TB, prompting the World Health Organization to declare a Global Health Emergency.  Following reinstatement of services, TB levels fell dramatically, illustrating the follies of the short-sighted cutting of preventive services.  
Following the fall of the Berlin wall and the breakup of the USSR, there was fragmentation of Public Health (particularly vaccination) services in Russia compounded by population dislocation and massively increasing poverty. Between 1990 and 1993, almost 13,000 cases of Diphtheria were identified in Russia and its former satellites, resulting in more than 4000 deaths, due directly to the reduction in preventive vaccination services.
These examples illustrate that all medicine (and Public Health Medicine in particular) is unique among professional disciplines in that it seeks to remove the reasons for their very existence.  Falling levels of diseases are not headline catchers; it is only when such preventive services are removed that we see the damaging effects of mounting levels of disease, the initial cases invariably arising among the most marginalised. In the last fortnight, we have seen an outbreak of Influenza in a nursing home in Donegal, leading tragically, to a number of deaths among its frail, vulnerable, elderly residents. Such incidents, thankfully rare, illustrate the dangers that infectious diseases still pose, especially for our mostdefenceless citizens.  
Funding reductions disproportionately affectthe poorest and most marginalised in our society, leading to a widening in health inequalities.  Such is the importance of this issue, thatthe IMO have produced a Position Paper on Health Inequalities, and we have devoted a complete scientific session on Thursday to Inequalities; Bridging the Divide – Addressing Inequalities in Health.
Absolute poverty affects the likelihood of developing disease (for example, middle class Irish men die in their late 70s, whereashomeless men die in their 40s), but there is compelling evidence that relative deprivation can affect health. A series of studies in the 1960s and 70s looking at Whitehall civil servants examined the effects of relative deprivation, in a population that would not be described as deprived, in any normal sense of the word.  At this time there was a popular perception that people in high-pressure jobs had the highest risk of cardiac death.
Contrary to popular belief, the researchers found that the lowest grade in the British civil service (clerical staff) had four times the chance of dying of heart disease than the highest civil service grade (the “Mandarins”).  They assumed that this was due to greater levels of smoking, unhealthy diet, excess alcohol consumption and lack of exercise.  They found that lower grades did indeed smoke and eat unhealthy foods more than senior grades but when they analysed their findings in depth, they found these “known” risk factors (smoking, unhealthy diet and excess alcohol) accounted for only 25% of the extra risk.  When they drilled down deeper, they came across more surprising findings; among the Mandarins, position, power and controlwere, in fact, protective.  In other words those who felt themselves to be arbiters of their own fate, those who were in control of their lives at work and at home, lived longest and had least disease (including heart disease and cancer) and disability.  Those who did not feel this way, who felt that they were individuals upon whom life “acted”, were more likely to die young.  Startlingly, these researchers demonstrated that social inequality was a more powerful risk factor for heart disease than cigarette smoking.
Inequalities exert their effects though stress; lack of control is stressful. We know that many of our citizens are living under such conditions of stress; either jobless, worried at the prospect of losing their job or terrified at their inability to service a crippling mortgage.   And, as more people find themselves in this situation, they will increasingly require the services of the State including the health service. Recent data from Social Justice Ireland indicates that more than 700,000 people in Ireland are now living in poverty, including 200,000 children.  This represents an increase of 92,000 people living in poverty in the last two years.
Reduced public sector funding will reduce the availability of services and will erode the social safety nets what have been carefully constructed over the last number of years.  These will, undoubtedly, have the effect of increasing inequalities in the medium and longer terms.  
There is another compelling aspect that extensive research is beginning to highlight; in an unequal society, not only are the disadvantaged worse off, so is everybody else.  
The US has one of the world’s highest income gaps between the richest and poorest 20% of the population - the income gap between these two groups is more than eight fold.  The equivalent gap for the UK (with the third highest income gap) is seven fold, in Ireland (with the tenth highest income gap) this gap is six fold, while the most equal countries in the world – Japan and Sweden – have an income gap of four or less.
In less equal societies, people engage less, leading to declining trust and social cohesion, driven, in part by the perceived unfairness of the manifest financial accomplishments of others, leading to greater levels of socially damaging behaviour. For example, the US imprisons people at 14 times the rate of Japan.  The unequal countries listed above, on average, the homicide rate is ten times higher than in the most equal countries, the teenage birth rates are six times higher, obesity is six times higher and infant and childhood mortality are increased.  Moreover, people in less equal countries live on average three years less than those in equal countries.
In other words, if we tackle inequalities, everyone in society benefits.  
Despite the fact that the economic conditions are challenging, there are reasons to be optimistic.  Economic indicators for Ireland are beginning to improve, despite the fact that we have still some way to go to get to still waters.  We look forward to the redesigning of the current health system, for the best time, paradoxically, to bring about change, can be during a period of flux.  The health system will, of course, be dependent on our national economic recovery.  
The next most important factorin our recovery will be our staff.   When the economic recovery gets into its stride, it will be the professionalism and energy of our young health care professionals which will drive the recovery within the health system.   Mahatma Ghandi said, “Be the change that you wish to see in the world” and the medical practitioners of the IMO, with their adopted stances on a fair and equitable health system devised as part of a fairer and more equitable society, signpost an ethically valid direction for this country to take. 
Doctors will play a central role in the development of the new health service.  Doctors have not, until recently, been included in clinical leadership or strategic clinical development within the health system; that has begun to change with the establishment of the Clinical Strategy and Programmes Directorate of the HSE, recognition that the running of the health service requires the input from medical practitioners.
I think it will be very important that we use the opportunity of our economic problems to redesign our health system, building in greater efficiencies.  The system itself should be patient centred and joined up.  In other words, funding should follow the patient, the system should be run in such a way as to minimise blockages in admission and discharge, there should be greater emphasis and training in working in teams so that skills are matched to the need of the team and the patient.  Too often we hear of mistakes ranging from missed out-patient attendances to the death of patients.

When such tragic events occur, we should look to re-engineering our system to minimise the likelihood of such an event ever occurring again.  Quality, in other words, should be built into the system. We already can see this approach being adopted with the work being undertaken by the Royal Colleges, the Medical Council, the HSE and HIQA.  A partnership approach between regulatory agencies, employers and practitioners that identifies the most effective and efficient ways in which to deliver quality services and to determine achievable benchmarks of performance is that most likely to succeed.  And the tools for this are being developed.  The National Quality Assurance Intelligence System that has been developed by Public Health allows individual surgeons and hospitals to map their performance against a range of benchmarks agreed with the Royal College of Surgeons.  Such monitoring systems will allow the system to more accurately determine where are the obstacles to free movement of patients that bedevil our Acute Sector.
The current two-tier system however, places such obstacles to the delivery of equitable, effective and high quality services that the entire system needs to be reconfigured.  This cannot take the form merely of structural reform.  We in the IMO believe that health is a basic human right, and that access to health services must be based upon medical need and not ability to pay.  This requires a cultural and ethical shift in mind-set.  The right to a healthy life, the right to health services based upon medical need must be explicitly stated and should colour every aspect of our new health service. 
The IMO is signally in favour of a single tier system based on the medical needs of patients rather than their ability to pay – the issue of the market model of healthcare was debated earlier and generated intense debate with a clear majority of the opinion that such a model is not the best option for Ireland.
To date, we have not seen any plan for the Government’s proposed system of Universal Health Insurance and there are numerous models from which to choose; the key will be choosing a fair system that adequately ensures the health of all, that ensures that best practice underpins the working of professionals and that is tailored to the needs of the Irish State. The IMO has called for a public debate about the development of a fair, one-tiered system ensuring adequate stakeholder involvement, access to detailed plans and funding mechanisms, stringent analysis of current and future manpower resources and a realistic timetable for implementation.
Recently, there has been a considerable amount of chafing regarding the public and private sectors.  From the identification in the Middle Ages of the Three Estates of the Realm (the nobility, the clergy and the Commoners), there has been a tension between commerce and merchants on the one hand who felt that the State (in terms of the clergy or nobility and latterly Government) on the other should interfere with the smooth running of business and wealth generation as little as possible.  That dialogue continues until this day.  I believe there is a fundamental failure for each to recognise the challenges of the other.  
The reality is that the public and private sectors are crucial to the financial and social health of any country.  The public sector aims to provide services that benefit the public as a whole, as it can be very difficult to accurately price and charge people for services and costs at an individual level can be prohibitive. The Government tends to provide these goods and services at a cheaper price than if they were provided by a profit making company.  To ensure smooth running of relatively static services, a degree of stability is required.
The goal of businesses in the private sector is to maximise shareholder return and to make a profit.  A rapidly altering landscape means that private companies must be constantly adapting; constantly searching for new staff with emergent skills resulting in a high staff turnover.  
The Public sector can learn from the Private sector especially in terms of ensuring performance and taking responsibility.  In the Public sector complicated structures and reporting can make it difficult to determine where responsibility and authority lie.  I have always believed that medical practitioners (even in the Public Sector) have behaved more like Private Sector counterparts as we have had, from our first day on the wards, to take responsibility for our actions, ensuring that we can explain and defend each action and decision.
In any Society, Government and the judiciary govern and ensure that the law is formulated and enacted, commerce and business provide the engine of a society while the public sector is concerned with fashioning and maintaining the fabric of Society. The Public sector and the Private sector are both necessary for a healthy society.  The IMO recognises that one of the greatest enhancements to a nation’s Public Health is the provision of rewarding and secure employment; the public and private sectors must work together to ensure that as many of our citizens have the opportunities to be employed in as healthy a way as possible.    
Arguments are put forward that the remuneration of medical practitioners in the public sector is too generous.  In fact, using recent OECD comparative data, Ireland is not among the top six countries of the OECD, which have the most highly remunerated specialists.
Medical specialists, General Practitioners, Community Doctors and Non-consultant hospital doctors have taken their public sector pay cuts along with the rest of the public sector and prepared to do what is necessary to see our country returned to financial health, but the load must be shared equally and calculations based upon fact and not on inaccurate or incomplete data.   
To ensure that we remain in a position to influence the direction taken by in the redesign of our health system we can only do this if we have sufficient power.  The power of the IMO comes from its members, 6,143 doctors focussing their efforts in a single direction.    And it extremely important that we ALL direct our labours in thatSINGLE direction, whatever that direction happens to be.  The views of individual doctors are generally taken seriouslyand so much more so when the views of all doctors are channelled into a single message.
As doctors who are expert in one area, we can occasionally assume that we are expert in all areas including industrial relations.  My job as a member of the Public Health committee is to provide crucial background and expert knowledge to allow the industrial relations experts in the IMO Secretariat to fashion compelling arguments to ensure that we maintain our terms and conditions. 
Often, the issues that must be dealt with by the Industrial Relations division of the Organisation can evoke high passions and hot heads on all sides – the job of the IMO is to ensure that the view of cooler heads prevail.  Views can differ but during negotiations, mildly differing views that vary in superficial ways can be interpreted as being deeply divergent and contrasting,and such division can be used to weaken arguments.  This is why it is crucial toensure that we present a united front.  It has been by focussing this united front that the Organisation has managed to obtain and maintain so much for us over the years.  And our united front has so much to give to this country and our patients; our patients are for whom we go to work each day and who remain our overarching priority.
When I was a Registrar in General Practice, among my patients was a young English familyin a friendly East Anglian town; two parents and a young daughter.  I'll call the mother Olivia and the daughter Laura.  Laura was a pretty, bubbly inquisitive 5 year old; I knew her through infrequent upper respiratory tract infections.
One Spring morning, Olivia brought Laura to see me. Laura had woken up vomiting for three mornings in a row; she had recently become “clumsy” and was complaining of a headache. Laura had bilateral papilloedema and a mild right sixth nerve palsy.  I outlined my concerns to her mother, telling her that there may be a possibility that Laura had raised intra cranial pressure and I went through the worrying differential diagnoses.  Laura was directly admitted to the local paediatric unit.
The next afternoon, I got a phone call from Laura’s consultant to say that she had a large cerebellar tumour;probably a medulloblastoma.  The outlook was pessimistic, but the tumour might be amenable to surgery and radiotherapy.   I went to visit Olivia; she was profoundly shocked.  I pointed out the great advances in surgery, radiotherapy and chemotherapy, telling Olivia that Laura would be transferred to an internationally renowned centre in London.   I pointed out that children did survive this type of cancer and that there was always, always hope.  
Over the next six months I visited Laura and her mother regularly during successive bouts of radiotherapy and experimental chemotherapy.   Olivia was always strong; Laura tired but constantly cheerful. By late October Laura's condition had worsened; she was unable to go home at all.  Three weeks before Laura's sixth Christmas, Olivia rang me to tell me her only child had died peacefully in hospital during the previous night.
After my Surgery, I went to visit Olivia, her husband and Laura in their home.  I watched wordlessly as Laura's parents wept, holding her pale hands as she lay in her tiny, white coffin.  A week later, Olivia and her husband buried their only, beautiful daughter.
I visited Olivia fortnightly until, after about four months, she told me that she felt that she didn’t need to see me anymore; I was glad that she was feeling stronger.  I didn’t see her for almost a year, then one day as I was walking through the local town centre, I felt a tug at my arm.  It was Olivia, looking brighter and smiling. We chatted, thesubject eventually turning to Laura.  She told me how hard the first few months had been but in the last few weeks she felt she was beginning to turn a corner.  She then told me that she was about twelve weeks pregnant and would be coming soon to see me.  Suddenly she began to cry, shuddering and gasping, tears rolling down her face.  In a shop doorway, I held her silently in my arms, oblivious of passersby. Recovering her composure, she thanked me and she said she would book in shortly for an antenatal visit.  
Olivia and Laura were not my customers; I didn’t “sell” them their healthcare.  They were not my clients; ours was not a business arrangement, concerning the exchange of goods and money.  They were my patients; my purpose was to develop with them a deep and important human relationship, to treat them, to care for them, to accompany them.  I feel privileged and fortunate to have known them, to have cared for them and to have accompanied them on their dreadfully difficult journey, journeys that every doctor in this room have travelled.
I want to thank my medical colleagues in the IMO;they have taught me much in my years in the Organisation.  I want also to thank my colleagues in the HPSC, constantly understanding of my many absences on IMO business. I want to thank our outgoing President, Ronan Boland, he has been a very safe pair of hands and a tireless medical advocate.  I want to congratulate our incoming Vice-President Matt Sadlier  -I look forward to working with Matt in the coming year.  
I want to thank the IMO secretariat and acknowledge their tireless professionalism; on a daily basis they manage to keep me out of trouble.  I want to particularly single out George McNeice; I have found George to be a very wise and able negotiator and a very decent human being.  His quiet strength continuously inspires me.
I want to thank my family – my daughters Anna and Rosie, they remind me every day of just how intensely proud I am of them.  And finally my wife Marian – I hear many men say that they would not be where they were, had it not been for their wives; in my case this is absolutely true.  Her patience, love and understanding are what enable me to live the life Ido, and I am eternally grateful to her.
I will finish by saying that I am proud to belong to this profession; I am proud of the work doctors do and have done for thousands of years.  I am proud of the fact that the cornerstone of medical practice is to care for, to protect and cure those who are less fortunate than us.  I am proud that the work we do makes a difference; that patients, in the main, remember us for our care, our support and our kindness.  I am proud to be a public health physician, to belong to a specialty whose core aim is to ensure the health security of the State and whose primary function is to prevent – to ensure that people do not fall ill and if they do in the smallest possible numbers with the least impact on their personal lives, on our economy and on the running of this State.  
Finally I am proud to belong to this Organisation - the voice of doctors everywhere.  When I travel abroad and mention the IMO, I never fail to be surprised to hear how many non-Irish people are aware of its existence and of the work it does.  I am proud that over the course of almost two centuries, this Organisationhas remained true to its establishing principles, attaching importance to the same issues today as its founding fathers did so long ago, ensuring that our patients remain our priority.  By following these fundamental principles I believe we can continue, as we have been doing for decades, to do much to ensure that all our patients, all our citizens, have the opportunities they deserve to flourish and prosper in health and happiness.  Thank you

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