Comments by Micheál Martin T.D., Minister for Health and Children at the launch of the Clinical Indemnity Scheme incident reporting system (STARS)
At the outset I must say how pleased I am to attend what I believe is the first formal occasion associated with the Clinical Indemnity Scheme. As this audience is well aware, the process of getting the Scheme up and running has been a long and difficult one. I believe that the effort has been worthwhile and that, in time, the Government’s decision to go for enterprise liability as a solution to emerging problems with indemnity costs in 1999 will be accepted as a far-seeing and enlightened one and that its persistence in seeing it through many difficulties will be justified.
There is a widespread effort to spread misinformation about what is, and what is not, covered by the Clinical Indemnity Scheme. Everything which a doctor does associated with his or her job in a public hospital is covered by the Scheme. This includes the consultants’ private patients in the public hospital. They are not being asked to contribute a Euro to the cost of providing them with this cover. This is in stark contrast to their colleagues in NHS hospitals in the UK who must pay for cover for their private patients.
I believe that the decision taken by the Government was the correct one. Commercial insurers have, by and large, withdrawn from providing professional indemnity cover for clinical activity. The cost of buying cover for consultants has continued to increase. We only need to look at the chaos which has unfolded in Australia following the collapse of the largest mutual provider of indemnity cover there to see what might have so easily happened here if the Government had not acted by deciding to establish the Clinical Indemnity Scheme.
The Clinical Indemnity Scheme and Risk Management
However the establishment of the Clinical Indemnity Scheme has never been just about the cost of indemnity cover or the arrangements for managing claims. If those objectives were to be the limit of our ambitions we would have missed a major opportunity to reduce the number of adverse events which ultimately lead to claims. The rationalisation of the indemnity arrangements eliminates one of the major barriers to comprehensive incident reporting and investigation. However the introduction of the new Scheme also presented the opportunity to put a comprehensive reporting system in place. Such a system was required in any event to allow hospitals covered by the Scheme to report claims to the State Claims Agency. It was decided at an early stage to take the opportunity of putting this system in place to provide hospitals with a state of the art risk management system to allow them to investigate and analyse their own incidents and claims. It was also decided that, if at all possible, the system selected should allow hospitals to record their public liability incidents, employer´s liability incidents and complaints in the one system.
The STARS System
At the outset it must have seemed unlikely that a single software system could be found that would meet all of these diverse needs. Following public advertisement and tendering procedures the STARS System developed by Marsh was selected. It has been adapted for Irish use and is in the process of being tested at eight agencies at present. It should be available to all major agencies covered by the CIS by the end of March. This is a remarkable achievement as I understand that the project is on schedule and will be brought in under budget. I believe that this is not always the case with large scale IT projects.
As a result of the decision to put such a system in place, Ireland will probably be the first country in Europe to have a national clinical incident reporting system. The only other country working on such a system is the United Kingdom which is developing a system from scratch. Having such a system is likely to be one of the key recommendations of a Council of Europe Expert Group which is currently working on measures needed to enhance patient safety. Having this system already in place will put Ireland to the fore in having the basic infrastructure for a patient safety strategy in place. We can reasonably expect that having the system in place will generate significant interest from other countries and I am sure that the Department, the State Claims Agency, hospitals and Marsh will be generous in sharing our experience with other countries which are sure to follow our lead in this area. This project is also unique in that it is the first major health IT system to avail of the Government’s Virtual Private Network (VPN). The VPN will provide health agencies with access to the STARS system on a faster and more secure basis than that provided by the public internet. This is critical as the information to be collected and distributed through the system is highly confidential. I think this is a fine example of what technology can provide to the health system and begins to give real meaning to the whole concept of eGovernment.
Benefits of the System
An obvious question to be asked is “What benefits will the system deliver?” The collection of data on adverse incidents is not an end in itself. The data must be put to some use. This information is not being collected to identify doctors and nurses who make mistakes in order to punish them. It is being collected so that individual hospitals and the system as a whole can learn from the mistakes that are inevitably made in a system the size of the Irish health service. We know from claims that are taken against hospitals and doctors that, to some extent, the same mistakes keep being made. One explanation for this phenomenon is that there is no systematic analysis undertaken of what mistakes are made and why they are made. Good data on the incidents which do occur is the first step in gaining an understanding of the problem. This information is really required so that we can learn from it. That is why we want hospitals to have that information. Not for any other reason.
As you know there has been some debate recently about the likely rate of medical error in Ireland. The reason why there is a debate is simple. No research has been undertaken in Ireland to establish the extent of the problem here. However this problem has been investigated in other countries through large retrospective reviews of case records. These reviews have been conducted by clinicians. The landmark Harvard Medical Malpractice Study found that 4% of patients were unintentionally harmed by the treatment they had received. 7% of these patients suffered some permanent disability and of these 14% died partly as a result of their treatment. These findings were replicated in studies in Colorado and Utah. A study in Australia found an adverse event rate of 16%, about half of which was considered to be preventable. A small study conducted in the United Kingdom indicated a 10.8% adverse event rate, again about half of these were deemed to be preventable. What these studies make clear is that medical error is a serious and widespread problem in developed countries. If you examine this evidence at all you cannot find any reason to suggest that a study undertaken in Ireland would produce results that were any different. Because of the opportunity which the commissioning of the STARS system presents I believe that we should look at what might be done to ascertain the nature and extent of the problem in Ireland. With that in mind I have asked officials of my Department to work with the Health Research Board on designing a study which, among other things, would attempt to quantify this problem.
However I don´t think that we can, or should, wait until research is completed to begin to formulate a strategy which has as its central objective the enhancement of patient safety in all services. And, I don’t just mean acute hospitals. In devising the new health delivery structures I will be asking that patient safety be designated as a key component of the new structures. We have already put several of the key components in place, such as the accreditation scheme, the enhanced role of the Irish Medicines Board and now the STARS system. What perhaps still needs to be done is to develop a strategic vision for patient safety which integrates these initiatives and provides a framework for their full implementation.
In conclusion I would like to thank all those who worked to bring this project to where it is today. These include officials of my own Department, the State Claims Agency, risk managers and IT specialists from hospitals and health boards, the Marsh STARS team in London, our legal, procurement and risk advisors. I am particularly pleased that Jeff Markowitz from the STARS global headquarters in Chicago was able to join us today. From the inception of this project we have had a very productive relationship with Marsh, both as our advisors on the Clinical Indemnity Scheme and with STARS. On a personal level I would like to take this opportunity to thank Stephen Byrne and Fergus Clancy who have helped us deal with the many complex issues which have had to be resolved to bring this project to where it is today.
Thank you all.