Dr Stephen McWilliams recounts the life and work of physician, writer and quintessential Renaissance man Francois Rabelais

The book is a very old invention indeed. As early as the seventh century, the Chinese were using ink on carved wooden blocks to print images onto paper; by the 14th century, the earliest paper mills were springing up around Europe; and by 1423, the Europeans were using block printing to manufacture books. This allowed the subsequent manufacture of a mass-produced bible by Johannes Gutenberg. From then, it was only a matter of time before people began writing novels.

One of the first to do so was Francois Rabelais. He authored a series of five novels, collectively entitled The Life of Gargantua and of Pantagruel. Essentially the epic adventures and chaotic mishaps of two giants, the novels were written in a famously crude, satirical and occasionally-violent manner, with several chapters displaying lengthy, coarse narratives clearly designed to offend.

The first in the series was Pantagruel (1533), published under the pseudonym ‘Alcofribas Nasier’ – an anagram of the author’s real name. This debut was followed a year later by its sequel, Gargantua. The protagonists were father and son, and the latter was thought to be a thinly-veiled satire of Henry II of France. Gargantua was equally noteworthy for its social commentary, such as the call for educational reform and for free schooling for all.

Despite their weighty substance, the novels were criticised for having poor literary structure. Moreover, early versions of the first volume supposedly described two giants that appeared inexplicably to vary in height. At one point, the creatures were described as large enough to allow the narrator to reside in Pantagruel’s mouth for up to six months, while on another occasion they were small enough to permit the eponymous hero to gain access through the doorway of a courtroom.

Novel works

Notwithstanding, both novels were enormously successful. They were reprinted nearly 100 times during the 16th century, although it is thought that Rabelais made little money from his writing. The third, fourth and fifth works – perhaps less well known – were entitled Tiers Livre (1546), Quart Livre (1552) and Cinquieme (1564), literally the third, fourth and fifth volumes respectively. There are claims by notable academics that the latter, published more than a decade posthumously, may have been edited or even written by other authors. Either way, Rabelais is thought to have influenced numerous subsequent writers, including Jean de La Fontaine, Victor Hugo, Voltaire, Honore de Balzac, Jonathan Swift and Laurence Sterne.

So, what is known about Rabelais? He was a doctor who lived around the same time as King Henry VIII of England. At one point, he even petitioned the Pope to revoke the king’s excommunication from the Catholic Church.

Destined to become a timely example of the Renaissance man, he was born (as far as we know) in 1494 near Touraine, France and was the youngest son of a local lawyer and landowner. A pious man, he became a Franciscan monk at the age of 27 but, soon after, acquired special permission from Pope Clement VII to switch to the Benedictine monastery of Saint-Pierre near Poiters instead, where he was secretary to Geoffrey d’Estessac, Bishop of Maillezais.

Anatomy lessons

After spending some time studying law at the University of Poiters, he set his mind instead upon medicine, acquiring a degree from the University of Montpellier when he was 36. He moved to Lyons, where he worked as a proofreader for Sebastian Gryphius, a German printer of some repute. His medical career continued in parallel and, in 1532, he was made Chief Physician at a prestigious hospital in Lyons.

At the age of 41, he was made Doctor of Medicine and began lecturing at the University of Montpellier on subjects including anatomy, Galen and Hippocrates. He was among the first to teach anatomy using the dissection of corpses.

As his reputation grew, he became personal physician to Cardinal Jean du Bellay of Paris. This led to Rabelais working for the Cardinal’s brother, Guillaume du Bellay, Lord of Langley; subsequently, the renowned doctor became Master of the King’s Requests (King Henry II of France). Rabelais was soon appointed Canon of St Maur and finally, by 1550, he was the non-resident cure of Meudon, a position from which he resigned in 1553, shortly before his death.

Medical texts

During all this, of course, Rabelais was a prolific writer. Following his early work as a proofreader, he acquired a position editing medical text books. He published in his own name from 1532 onwards, and began with a translation of Dr Jean Manardi’s Medical Letters and one of Hippocrates’s Aphorisms. He also wrote extensively on archaeology, and edited a Topography of Rome.

Although a distinguished man of letters, Rabelais was nevertheless considered gregarious and even cunning, while his works of satirical fiction were thought rather unbecoming of a man of the cloth. Indeed, Rabelais gave rise to the term ‘Rabelaisian’, meaning exuberantly imaginative with coarse humour.

Rabelais died on 9 April 1553 and was buried in St Paul’s Cathedral, Paris. History shows him as an archetypal example of the Renaissance man, with a pious nature, an interest in law and ethics, a pioneering influence over the teaching of medicine and a flair for creative writing. Mischievous and bold in his literary endeavours, he set the standard for novelists almost from the point at which technology allowed this medium to exist. And, as we have established, the book is a very old invention indeed.

The science of epigenetics may hold the key to our understanding of mental illness and behavioural disorders, Dr Bill Walsh tells Aoife Connors

I’m so excited about epigenetics,” Dr Bill Walsh told Irish Medical Times, ahead of his visit to Trinity College last week (17 July) for a conference on ‘Nutrient Therapy Protocols for Mental and Behavioural Disorders’.
Dr Walsh was set to address the Dublin Outreach Conference, focusing on the emerging science of epigenetics. In 2008, this chemical engineer founded the Walsh Research Institute in Naperville, Illinois, which is organised exclusively for research, educational and charitable purposes.
“This is the most exciting thing that’s happened [in medicine] in 40 years. It appears many of the diseases we thought were genetic are actually epigenetic,” he said. “Epigenetics has the advantage that it can lead to therapies that can reverse what genes are doing.”
This scientific field, explained Dr Walsh, is the study of inherited changes in phenotype (appearance) or gene expression, caused by mechanisms other than changes in the underlying DNA sequence. Epigenetics “provides a roadmap to more effective therapies for mental and behavioural disorders, because the primary method for helping these kinds of problems over the last 30 to 40 years has been psychiatric medications”.
“I think our next step will be to use our knowledge of molecular biology and brain chemistry to find ways to directly correct neurotransmitter and receptor problems,” he said. “We’re getting closer to understanding exactly what goes wrong and reversing how this occurs. If you look at the science of epigenetics for various disorders, methylation appears to be the most powerful factor in epigenetics and genes expression.” Methylation contributing to epigenetic inheritance can occur through either DNA methylation or protein methylation.
Cure for all cancers
Epigenetics is also on the threshold of revealing why people develop certain cancers, said Dr Walsh: “We know in many cancers that numerous suppression genes are shut off, but this is just the beginning. I think we’re very close to a cure for all cancers.”
The scientist says he has treated some 25,000 people with mental and behavioural disorders in Australia, New Zealand, the US and Europe, accumulating a significant database with biochemical information on people with mental and behavioural disorders.
In 1982, he founded the Health Research Institute in Warrenville, Illinois and in 1989 set up the associated Pfeiffer Treatment Center (HRI-PTC) there, where he was president until 1998. Following this, he became HRI-PTC Director of Research until June 2008, when he established the Walsh Research Institute. Dr Walsh has since concentrated on research and practitioner training in advanced nutrient therapy methods to treat mental and behavioural disorders.
He firmly believes nutrient therapy can be the key to treating such disorders. “There’s a belief that you need a powerful drug to treat a problem like schizophrenia, a chronic mental-health condition or bipolar disorder. But I think a lot of doctors have forgotten what they learnt in medical school – where do our neurotransmitters come from and then what controls them? What factors affect neurotransmitter uptake and the process of synapse?
“When you dig into the molecular biology of this, you find nutrient factors are extremely important. If a person had a genetic disorder that caused them to be very deficient in vitamin B6, well, this is the major core factor in the production of serotonin. So if a person has a major B6 deficiency, you can be sure they’ll be low in serotonin and will suffer from depression, or at least have a tendency for it.”
The solution could be to prescribe fluoxetine, or selective serotonin reuptake inhibitor medication, to help with the side effects. “But it seems a lot more scientific, if a person is depressed, to simply normalise their B6 levels. If you do a complete metabolic analysis of any human, you’ll find they’ll probably be low in five or six important nutrient factors because of genetics and epigenetics. If you could identify those, the person may benefit from many times the RDA of those nutrients, because they’re fighting genetics,” Dr Walsh explained.
The treatment weapons he uses are amino acids, fatty acids, vitamins and minerals, focusing on the nutrients that have a powerful impact on the synthesis of neurotransmitters or what happens when an electrical impulse crosses the synapse, he explained.
Prison study
Over 30 years ago, Dr Walsh studied a Chicago prison population while the offenders integrated back into society. Doing chemical analysis of blood, urine and tissue samples, Dr Walsh and his team found most of the prisoners had major deficiencies in copper, zinc and manganese levels. “There are about 35 different metals in the body. As a group, the offenders had very abnormal metal metabolism. We found many different forms of behavioural disorders, but the anti-social personality group had a distinct pattern.”
The study showed each of the offenders had high blood histamine, zinc deficiency and were under-methylated: an abnormal combination of chemical imbalances. The offenders needed nutritional therapy, not medication.
Another study looked at more than 10,000 adults and children with severe behavioural problems. People with obsessive-compulsive disorder, oppositional-defiant disorder or seasonal depression had completely different chemistry. “They fit into very different classifications: not only are their biochemistries uniquely different, but also their symptoms and traits are very different.”
People with these conditions tend to be under-methylated – low in serotonin levels, calcium, magnesium, methionine and vitamin B6. “We found a lot of the children studied had attention deficit hyperactivity disorder (ADHD) or insulin deficiency. Families reported that not only did the children’s behaviour improve, but their school work got dramatically better when nutritional therapy commenced.”
He has conducted many studies on the relationship between biochemical therapy and behaviour outcomes. In 1989, Dr Walsh opened a clinic to treat behavioural disorders, ADHD and later schizophrenia. In ten years, this has become the largest clinic of its type, having treated over 35,000 patients. “We had the highest population of autistic patients, so we did a combination of scientific research and clinical protocols aimed at normalising the nutrient factors that impact on brain chemistry. Our clinical goal with a patient was to normalise their blood levels and their brain-chemical levels.
“It seems to work very well for certain populations, but unfortunately we failed to help children with Down’s syndrome because they had particularly unusual brain and body chemistry. We did a careful study of Down’s kids and found the treatment didn’t help. But every time we’ve done an outcome study on behaviour, depression, eating disorders, autism or schizophrenia, we got positive results on the individual’s behaviour and the family reports.”
Methylation
Dr Walsh has studied the methylation status of over 25,000 people with various mental and behavioural disorders. He believes that methylation has a powerful impact on epigenetics. “If a person is over-methylated or under-methylated, it affects which genes are turned on and off. This has a lot to do with production of proteins within the brain and body and where that has gone wrong.
“In early foetus development, a number of decisions are made and these get ‘bookmarked’,” he explained. “Some genes are turned on in certain tissues, while others are turned off. Although a natural process, for some people, things can go wrong and people can end up with a pre-disposition for depression, a mental illness or behavioural disorder.”
Many of these conditions have perplexed scientists for years, because illnesses like depression run in families. “The problem is these illnesses violate the classic laws of genetics. I think we now have the answers because it’s really epigenetic and not genetic. The conditions don’t involve changes in the DNA, but the changes involved are alterations or modifications – or errors, you might say – in gene expression,” he explained.
Dr Walsh hoped that his presentation at the Dublin conference would succeed in its aim of getting ten to 20 Irish doctors interested in nutrient therapy. “We’re hoping to start a week-long Walsh Outreach Training Programme for doctors and medical practitioners in Ireland. This would be similar to the existing Australian scheme, where we now have more qualified physicians in nutritional therapy than anywhere else in the world.”
Dr Walsh has also expanded his therapy training programme to Norway and is currently working on establishing the programme in the Philippines.

Pioneering US medic Dr Lynn Holden tells Aoife Connors about her novel project to open up entry to medicine to the socially disadvantaged

Ireland could benefit from replicating an innovative American programme aimed at broadening opportunities to enter medical school, a leading US doctor has suggested.
‘Mentoring in Medicine’ is a novel US project that inspires young people from less-affluent communities in the States to enter medical school. The programme is successfully run in California, Atlanta and New York.
On a recent visit to Ireland, Dr Lynn Holden, President and Executive Director of the non-profit organisation ‘Mentoring in Medicine’, told IMT that Ireland could benefit by establishing something akin to the Bronx mentoring project and she would be delighted to help facilitate such a programme here.
She said the mentoring model gave students unique opportunities to pursue medicine that otherwise would never have been given to them. The project links students as young as seven years old with a professional working in a medical career in which they aspire to work.
The professional acts as a ‘medical mentor’ for the student throughout their study, often right through until the student reaches their final medical exams. There are no limits to who can take part in the programme, explained Dr Holden. “We take all comers. If you’ve a desire, we’ll work with you and expose you to the career path,” the Bronx doctor said.
Mentoring in Medicine
She told IMT that the mission of ‘Mentoring in Medicine’ was two-fold: to teach African-American children healthy living habits, and to introduce students to science and health professions. “The organisation does this in a variety of ways – with multi-sensory curriculum. We work with students from third grade right through to [medical] school, whether that be nursing, medical or pharmacy. The programme focuses on three areas: academic enrichment, leadership development and community service.”
While the programme has achieved much, the numbers are still an issue, Dr Holden acknowledged. “In 1919, 6 per cent of physicians in the US were African-American and today the figure remains the same.” Yet she believes that the longitudinal effect of the mentoring programme is that people from various socioeconomic and diverse backgrounds are given knowledge about healthy living and the opportunity to enter healthcare professions they never thought possible.
“When we talk about diversity, it covers many different aspects of life. But the most important thing we are striving for is to help those people living in areas where they might not be exposed to healthy living, where health literacy is poor and access to third-level education is limited.”
Students can choose to become attached to any one of more than 200 healthcare professions signed up to the scheme. As health professionals are very ‘time compressed’, the period spent with students is done in a very organised fashion, Dr Holden explained.
Each year the organisation holds a conference called ‘Yes, I can be a healthcare professional’. “The healthcare professionals come in for four-to-six hours and spend time with students talking about a particular subject, e.g. podiatrists will show the students a diagram of the foot and some instruments they use in the operating room. They may demonstrate some problems like taking care of bunions,” Dr Holden said.
Funding for the mentoring programme comes predominantly from philanthropic sources and various grants. Currently, Dr Holden has two continuously funded programmes: a high school programme in six New York schools funded by the National Library of Medicine and the friends of the Library; and a community ambassador programme funded by the American Heart Association and the American Stroke Association.
A lot of income support comes from academic institutions, including Montefiore Medical Center in the Bronx, which funds research grants and student scholarships. Dr Holden said: “A lot of students are not aware of the various grants and funding opportunities available to them, apart from taking out a loan or paying out of their pocket.” The ‘Mentoring in Medicine’ programme creates financial awareness amongst the students, so they can realise the different ways available to fund their education.
Dr Holden added that they like their students to practise in their own communities what is taught to them. “We spread messages for healthy living, because if the young people are interested in their mental health, it becomes their social responsibility, and they promote positive health to others.”
In an effort to target health literacy during the H1N1 pandemic last year, Dr Holden and her team downloaded information from the internet and the New York Department of Health, and recruited 150 college and high school volunteers to distribute the latest H1N1 health information to families, parents and the elderly throughout the city who did not have internet access.
“Every night, we had a conference call on what was coming out about HIN1 from the official websites. We downloaded and distributed the information in English and Spanish. We had students at subway stations during rush hour, handing out flyers with the latest information coming through the internet.” This, she said, helped to increase public knowledge of the pandemic. She believes something similar could be rolled out in parts of Ireland, particularly in areas where there is huge diversity within the local community.
Obama’s reforms
As a doctor in a busy emergency department (ED), Dr Holden believes President Barack Obama’s Affordable Care Act 2010 will certainly have an impact on the health system in the US and be “something very beneficial”. “Traditionally in the States, the EDs have been overcrowded — a situation called gridlock,” she stated. “I think Obama’s health reform bill will help alleviate some of the issues we’re seeing with overcrowding.
“The ED has traditionally been used as a first point of entry because of the lack of primary care physicians in the States. Patients may have to wait two-to-six weeks to see their physician, so they come to the ED because it’s open 365 days a year, 24 hours a day and they won’t be refused.” She is hoping the healthcare reform will provide more support in primary care, so that more preventive treatments can be put in place for patients and “we can pick things up earlier — prevent, rather than cure”.
Dr Holden’s main role in the mentoring project is to provide leadership for the team and students, and also to recruit volunteers and facilitate programme development. The Professor of Clinical Emergency Medicine at the Albert Einstein College of Medicine travelled to Ireland recently with her teenage daughter to address the annual Albert Schweitzer Leadership for Life International Youth Conference, organised by Foróige, the youth development organisation, in partnership with the Irish Chamber of Commerce USA Foundation. Speaking to a group of teens is challenging, Dr Holden informs IMT, as one has to be engaging and exciting.
“I wanted to grab their attention and inspire the young people to be leaders,” she said. Over 250 teenagers from North Korea, Nigeria, the US and Europe attended the week-long event, which enables young people to develop the skills, inspiration and confidence required to be an effective leader in their community. Dr Holden believes there is great potential in the Irish youth: “The possibilities to develop medical mentoring programmes here are endless.”
She told the group of potential future medics about the four keys to leadership and success, which she said helped her in her own life. “The first was ‘faith’ – both spiritual faith and belief in one’s cause. Second is ‘focus’ — practising the power of visualisation, where you want to be in the future, and keeping that goal in mind. Third is to ‘follow through’ – being able to continue if something doesn’t turn out the way you want it to and having the strength to brush yourself down and keep moving. The final key is ‘fired up’ – being passionate about your cause. If you don’t have the passion and you are not feeling good about it, then you won’t succeed.”
While spending a few days in Dublin, Dr Holden reflected on comparisons she saw between Ireland and the States, which were not always positive. “Walking through Dublin, I see the homelessness here like we have in the States, and I know the impact it has on people. Often when people come to our ED, it is not because of a medical problem but rather it may be the only place to go because they literally have no home to go to.”
Yet it was the friendliness of the Irish that struck her the most. “I’m never lost because there is always someone to give me directions.” And with that, I pointed her in the right direction.

Professional competence (PC) will impose a significant administrative cost on the ICGP, College Chairman Dr John Delap has told Irish Medical Times.
“If you consider the issue of logging and auditing the competence assurance process for 3,500 doctors, then there is obviously going to be a significant administrative expense in dealing with that,” he said.

While the North Dublin GP accepted that this would require substantial investment by the College, he pointed out that the ICGP had always been “to the fore” in communicating with its members and in the recording of their CME activity. “So we would envisage that we would do the same for the competence assurance process,” he said.
The source of the funding is currently uncertain but the Department of Health and the Medical Council take the view that it is up to professional bodies like the ICGP to provide initial investment in the process. Dr Delap acknowledged the funding issue needed to be discussed. “The structure will have to be put in place, and it is going to have to be funded. The initial funding will be expensive, but once it is in place, it will very much run itself.”
The ICGP will have a “core role” in providing the educational background and structure for competence assurance within general practice and GPs will be the single biggest group of specialists under the Council, Dr Delap pointed out.
But there was also an outstanding issue for those on the general medical register.
“The Medical Council has asked people to indicate which college they would identify with. Many will identify with the ICGP, but for doctors who are not working in general practice, who are not specialists in any area, it is not clear how competence assurance is going to be provided for those doctors.
“We’ve made it clear that we would be prepared to provide our facilities to doctors who are not members of the ICGP, but who are working in general practice. But there is going to be a problem for the Medical Council regarding doctors who are not on any specialist register and have no home for their continuous training and competence assurance,” he added.

The IMO believes the CA is incorrect regarding its negotiating powers, writes Aoife Connors

The IMO has rejected the claim from the Competition Authority (CA) that the existence of the GMS contractual relationship between the IMO and the Minister for Health has been one of the key impediments to reform of the medical card scheme.
Last week (July 9), the CA published Part III of a series of reports into general practice, entitled ‘Increasing Competition within the General Medical Services (GMS) system’.
The report states that implementation of the various recommendations made in the report would be “complicated” by the fact that changes in the GMS contract require amendment of the agreement between the IMO and the Minister for Health.
Effectively, the IMO must agree to the implementation of the recommendations first.
Dr Ronan Boland, IMO Vice-President and Chair of the IMO GP committee, told Irish Medical Times that he rejected the CA’s view on the IMO’s negotiating entitlements. “The IMO has an entitlement to appropriate representation and collective engagement with the State. That entitlement was recognised by the Government in December 2008, when it agreed to amend the Competition Act.”
In its report, the Authority suggests it may be easier and more effective to terminate the existing contract and begin “a new contract afresh”, rather than attempting to amend the existing agreement.
Competition between GP practices is restricted by certain features of the GMS system, the report states, as it favours existing practices and discriminates against newly-qualified GPs. Both public and private patients are affected by competition restrictions, because the CA says there is less pressure on GP practices to compete on price for private patients. There are also fewer GP practices from which to choose.
The CA has directed five key recommendations to the IMO, the HSE and the Minister for Health. The Authority has recommended that access to GMS contracts should be open to all qualified and vocationally trained GPs that meet general suitability criteria. GPs in possession of a GMS contract should be free to set up in, or move to, the location of their choice and the decisions to award a GMS contract in an area should not have to take account of the ‘viability’ of existing GP practices in the area, the CA recommend.
Dr Boland rejected these proposals: “It costs the State and the taxpayer a lot of money to produce a fully trained GP and, quite rightly, the State has maintained a stakeholder position in terms of the distribution and location of doctors. So while the individual doctor’s preference in terms of location is important, there is also a healthcare system to consider and for that reason, the IMO and I would not be in favour of complete deregulation.”
He told IMT that it was the IMO’s view that open entry to the GMS, allowing doctors GMS contracts in areas of their choice, would not be in the best interests of the GMS as a whole.
Dr Boland highlighted that in many parts of the country, there was a significant manpower shortage: “It’s difficult to get doctors. The manpower shortage is likely to continue in the medium- to short-term and, in a situation where you allow practices to be created in the location of their choice, historic experience has shown that doctors tend to gravitate towards more affluent, urban areas. This exacerbates the difficulties of getting doctors to work in less-advantaged areas.”
Surveys showed that doctors had a preference for working in a group-practice setting in an urban area and complete open entry would facilitate that, he said.
The CA has also recommended that the marking system for awarding GMS contracts should be amended to ensure applicants with similar levels of GP experience are awarded equal points, and that applicants already in possession of a GMS contract are not treated more favourably.
Finally, the Authority believes that payments to GPs under the GMS should be decided not on the basis of agreement with the IMO, but by the Minister for Health, following consultation with GPs and/or the IMO.
Dr Boland said: “This is no longer valid as the Government announced in the Public Service Agreement [Croke Park deal] that further discussions will take place with the Irish Medical Organisation — in relation to the Government’s commitment to make appropriate changes to Section 4 of the Competition Act 2002 — to enable the representative body of GPs, the IMO, to represent its members in negotiations with the HSE and the Department of Health in respect of the services provided to the public health service in a manner consistent with the public interest.”

Ombudsman Emily O’Reilly has described some of the healthcare-related cases in her 2009 Annual Report as “shocking and unacceptable”, reports Mary Anne Kenny

The Ombudsman Emily O’Reilly has described hospital treatment complaints profiled in her 2009 Annual Report as “shocking and unacceptable”. Of the 2,873 complaints made to her Office last year — the highest number recorded in over ten years – complaints against the HSE accounted for 26.3 per cent, down 1.2 per cent on 2008.
However, O’Reilly was highly critical of the Executive. At the launch of her seventh annual report as Ombudsman earlier this month (July 1), she urged the Government to root out a “rotten” culture of “excessive secrecy” in the HSE. She accused health chiefs of wasting public resources and frustrating her attempt to access vital family law records.
The report details some of the cases handled by the Ombudsman last year. One concerned a woman who complained about the care of her terminally ill husband.
“This was especially distressing, as was a complaint where I found that patients were experiencing disturbing ongoing and major deficiencies in hospital conditions at a public psychiatric hospital,” she said. “I can only describe these cases, particularly in the social and public healthcare services areas, as shocking and unacceptable.”
Maternity care
A woman complained about the standard of care she received at Waterford Regional Hospital (WRH) during the birth of her child in 2007. She claimed she had been deprived of pain relief because the attending midwife had failed to recognise that she was in labour. Her initial complaint to the hospital had taken two years to be examined.
The investigation found that due to neglect, the woman was deprived of the expert care and support of the midwife during labour, of having her partner or mother present at the birth, and also the opportunity to have appropriate pain relief.
“The woman had considered taking a legal case against the hospital but found she was statute bound (due to the investigation having taken so long to be completed). She came to me for assistance, seeking an apology for the pain she had suffered, counselling to help her deal with the trauma, and financial redress to reflect costs incurred in pursuing her complaint,” said O’Reilly in the report.
Negotiations with the hospital did not bring a satisfactory conclusion, no offer of financial compensation was made and, while the minutes of a meeting contained an apology, the woman felt this did not resolve the matter. After further discussions, the hospital’s manager agreed to write a full letter of apology, acknowledging that the woman had received sub-optimal care. Private counselling sessions were offered, the costs of which were met by WRH. The hospital also agreed to an ex-gratia payment of €1,000 as a goodwill gesture.
Hospital care
The Ombudsman received a complaint from a woman regarding the care her late husband received in the Midland Regional Hospital, Tullamore. She had specific concerns on: the manner in which her husband’s terminal condition was conveyed to the family (the hospital has since developed draft guidelines on breaking bad news to patients); that medication was left on his bedside locker; that his thromboembolic deterrent stockings (TEDS) had not been removed in almost three weeks; and that his nursing notes were deficient.
The nursing notes revealed that the patient’s medication was left on his locker when he was drowsy or unable to take his medication. “I suggested some staff receive refresher training on this aspect of drug administration. The hospital arranged for the issue to be addressed at nurse manager meetings and for its drug administration policy to be reviewed.”
With regard to the TEDS, the hospital suggested it was possible that they were changed more frequently than the complainant suggested. The woman had said that when she removed her husband’s stockings after three weeks, so much dry skin had come away that she could see the flesh between his toes. “The hospital developed comprehensive guidelines on TEDS use,” said O’Reilly. “I was reassured that lessons were learned… and a clear policy drawn up and implemented.”
With regard to the nursing notes, the Ombudsman asked the hospital to consider if it needed to review its record management policy in light of the National Hospitals Office Code of Practice for Healthcare Record Management. In response, it developed a policy and guidelines on best practice in nursing documentation.
“Furthermore, the hospital told me it completed a number of self-assessments in 2009. As a result, approximately 37 quality improvement plans were identified and the hospital is endeavouring to adhere to all the criteria from the various standards in this self-assessment.”
Psychiatric hospitals
The 2009 report identified major deficiencies in psychiatric hospital conditions. A woman complained about conditions in St Loman’s Psychiatric Hospital, Mullingar, where her father was a resident.
“My examination identified that the hospital seemed not to have complied with all of the recommendations contained in the Mental Health Commission Annual Report 2007,” said the Ombudsman. “It appeared there was noncompliance in relation to the introduction of multi-disciplinary team care-plans, provision of therapeutic activity, records management, residents’ personal property and possessions and privacy and physical accommodation, including toilet facilities.”
HSE officials responded that every effort was being made to address issues identified, but it was not always possible to rectify them within available resources. The HSE also said that, as a result of the sale of land to the local authority, €3.5 million had been earmarked to upgrade facilities.
“However, according to the HSE officials I dealt with, although they had intentions as to how the money generated would be used, there was no guarantee that it would be prioritised by the HSE corporately and/or by the Department of Finance for this service.
“The case speaks for itself. It is unacceptable and sad that psychiatric patients have to put up with a regime and facilities totally unsuited to their needs and that identify deficiencies not addressed,” said O’Reilly.
Child welfare
Last year’s report also included a chapter on child welfare and protection services. It gave details of cases examined by the Office, including: a grandfather fostering his three grandchildren who contacted the Ombudsman about the poor handover of case arrangement responsibilities between HSE regions; a complaint by a mother about the HSE handling of unfounded child-abuse complaints against her; and a complaint by a Midlands crèche that the HSE failed to communicate to it that a complaint against the crèche centring on child protection issues, after examination, was deemed not to stand up.
At the report launch, the Ombudsman revealed that during one investigation, her Office was led on an “Alice in Wonderland trip” around the legal system as the HSE tried to prevent a report being published: “I think there’s a huge issue around the HSE’s excessive secrecy and legalism. It strikes me that it’s a cultural thing. It’s redolent of a body that looks not to the public interest, which is the only reason it’s there, and seeks at times to protect its own interests, and that’s very wrong. It’s as if the HSE lives in a parallel universe.”
O’Reilly pointed out that others, including the Minister for Children and the Government, had not been able to secure information from the HSE recently in relation to child deaths in care, “so there’s something rotten within that system”.
In a statement, the HSE responded that its staff “makes every possible effort to provide information to and co-operate with the Office of the Ombudsman”, and pointed to its publication of reports on inquiries and investigations, HealthStat figures and performance reports as evidence of its transparency.

Dr Paul Heslin writes an open letter to Minister John Gormley suggesting a very simple solution that could save money, the precious time of emergency care workers and many lives

Dear John, it is my understanding that to be green is to look at the bigger picture, the long view and the system at large. It is not about local interests at the expense of our children, not about mé féin at the expense of the country, and it is not about short-term solutions that easily become a patchwork quilt of band aid solutions that later begin to leak like a sieve. Do you recognise the health system?
Ultimately, green is about systems thinking. How is everything affecting everything else? To be green is to ask is there a better, more sustainable way of doing things that makes more sense at local and national level, using resources more efficiently?
I want to tell you, therefore, how you could make my life as a doctor, and the lives of many front-line workers in this country, much, much easier. The citizens will also benefit and ‘systems thinking’ will get the credit. Joined-up thinking. This is a green, efficient solution that will make a real difference to all our lives. The positive consequences are for everyone, at a crucial time in our lives when we are most vulnerable, when we are sick or when our house is on fire. Cost savings and efficiencies are just an added bonus. Let me explain.
House calls
I regularly do house calls. I regularly spend a lot of time driving around looking for the number of the house. Yet I can often get frustrated at the waste and thoughtlessness of the system in which we all participate.
Many homes have no number on their doors, yet the owners seem confused that the ambulance, doctor or fire brigade does not get to their house fast enough. Some have the house numbers painted over thoughtlessly, now with the same green or grey colour as the door, making the number impossible to see, especially at night. Some neighbours do not know the street names of their own new estates.
In Australia in general, and in Melbourne and Brisbane especially, I saw other ways of doing things. The number of each house was painted on the slipway between the road and the footpath on the right side as you enter the house. It could be seen easily and safely from the car.
Also, the sequence of numbers was printed on the phone or electricity poles and an arrow indicating where these houses were. In the US, the mailbox is on the sidewalk with the number of the house. I would add to these great systemic practices.
All houses, by statute, should have their numbers in a reflective and easily seen form, all of a minimum size and font, on the right side of the gate, rather than inside the closed, dark door patio. All estates should also have, by statute, a map at their entrance detailing the street names.
I appreciate that sat nav has made a great contribution to the work of emergency workers. But it does not help at the local level. There is more that must be done, and we doctors see it at the coal-face. People who want and expect an emergency service must also be more thoughtful about how to facilitate the workers who are trying to help them.
Bells that do not work. Dogs barking and not put away in a back room. Patients gone shopping. These are not ways to help the system flow. What about the patient who is feeling better, but does not tell the emergency service? The patient who could come to the clinic, but will not? A preventable delay at one house means a delay before we get to the next house-call.
We are all in this system together. Perhaps that extra half hour will make all the difference at this most vulnerable time of one’s life. Do you want an emergency service that arrives at your house late, even too late? Do you want staff arriving frustrated and snapping at you?
Efficient system
As a doctor, I want to get from house to house in the most efficient way possible. It is satisfying to be working in an efficient system that gives the best possible ‘flow’ and that gives the best possible outcome. It is not like the old days, before mobile phones and cars, when an urgent call to the doctor meant being seen over the following two days, rather than in the same hour; when doctors travelled by horseback, boat and sometimes plane!
In some countries, this is still the way, as in New Zealand and Australia. But we are fortunate in Ireland. We can do better. But to do this, we need ordinary people to make changes that will help the helpers.
Minister, you are in the most powerful position to effect change at the level of government. Mary Harney made one small step for man, when she brought in smokeless fuel in Dublin, by one stroke of the pen. This effected a massive change in the health of Dubliners, with savings in euro, health outcomes and lives. We are all still reaping the marvellous benefits of this change in the system.
Now John, your time has come. Local authorities must bring in these changes. Take the opportunity now with both hands and do the right thing. Imagine fire brigades, ambulances, doctors and gardaí arriving at your door when you need them, rather than wandering around lost in the estates of Ireland, wishing they had gone to Specsavers!

Ed Madden, BL, looks at a recent Court of Appeal case in the UK, in which the Court allowed an appeal by a former senior health executive against a decision of the High Court that her severance package was unreasonably generous

On October 5, 2006, the Chief Executive of the Maidstone and Tunbridge Wells NHS Trust, Rose Gibb, ended her employment with the Trust under the terms of an agreed written settlement.
The termination had its background in outbreaks of the ‘superbug’ C. difficile at hospitals managed by the Trust, which led to the deaths of a number of people.
The Trust decided that the Chief Executive’s employment should be terminated prior to the publication of a highly critical report into the outbreaks by the Healthcare Commission, which was due to be published on October 10, 2007. The conclusions of the report were critical of the leadership of the Trust.
The terms of the settlement provided for a payment to Ms Gibb of £250,000, representing £75,427 in lieu of six months’ notice and a compensation payment of £174,573 (which approximated to one year’s salary).
For her part, Ms Gibb agreed to accept the immediate termination of her employment, and not to pursue any internal grievance or bring any contractual or statutory claim against the Trust. She also agreed not to make any statement potentially damaging to the Trust and not to disclose the substance of the settlement.
On the day after the publication of the Healthcare Commission report, Glen Douglas, who had taken on the role of CEO on Ms Gibb’s departure, received a letter from the Department of Health, instructing him to withhold the severance payment “until further notice”.
He complied with this instruction. Having been advised of this development, Ms Gibb issued proceedings in the High Court in which she sought to recover the full amount due to her under the terms of settlement.
Compensation
When the matter came on for hearing in the High Court in January 2009, the case focused on the compensation element of the settlement. By this time, Ms Gibb had received payment of the amount earlier agreed in respect of the six months’ notice period.
The Trust submitted that it was not obliged to pay the compensation element of the package on the grounds that the agreement it had entered into was “unreasonably generous” and ultra vires its powers. The High Court upheld this contention.
Ms Gibb appealed to the Court of Appeal, which heard the case in March 2010. The principal issue for the Court was whether the termination agreement was ultra vires and therefore unenforceable. In other words, had the Trust reached a decision so unreasonable, that no reasonable decision-maker could have arrived at that decision?
Giving his judgment in the case, Lord Justice Sedley said that “the making of a public sacrifice” to deflect press and political censure remained an accepted expedient of public administration in England. The Trust was aware that a damning report on its standards of patient care was shortly to be published by the Healthcare Commission.
The draft report, of which they had sight, included the following:
“The Healthcare Commission considers the findings of this investigation to be extremely serious, and to constitute a significant failing on the part of the trust, which failed to protect the interests of patients…”
In the light of such criticism, the sacrifice most likely to appease “the deities of Whitehall and the media” was the Trust’s Chief Executive, Ms Gibb. The fact that she personally had not done anything to warrant dismissal was a problem, but not an insuperable one. Provided that the Trust was willing to pay the necessary compensation, she could be dismissed without any notice and without good cause.
A vow of silence
The judge said that by accepting a compensation package that included “a vow of silence”, Ms Gibb would be sparing the Trust a public controversy around where responsibility for the scandal actually lay.
They would also be spared the near-certainty of an Employment Tribunal finding of unfair dismissal and a serious drain on management time and resources. There was also the potential damaging effect of all of these matters on staff morale and performance at a time when the Trust needed a new beginning.
This was the background to the “bizarre legal situation” now facing the Court. The Trust had been directed by the Department of Health to renege on its own agreement.
The reason for the direction was that Government ministers wanted to be able to announce that the termination agreement was being blocked. The Trust, when sued by Ms Gibb for failing to honour the agreement, had found itself compelled to deny its own power to enter into that agreement.
The judge said there was nothing irrational about the severance payment that the Trust agreed to in respect of Ms Gibb. On the scale of severance payments generally – not only in the private sector, but also in parts of the public sector – £250,000 was not outlandish compensation for the arbitrary termination of a career that it was unlikely Ms Gibb would be able to resume.
The Trust had been trapped “between a rock and a hard place” by interference on the part of the Department of Health, which had exposed it to substantial legal costs.
Central government, which would be picking up the cost, might have done better to recognise that the Trust, in reaching the agreement with its Chief executive, “had been making the best of a bad job”.
That bad job had been the decision “to sacrifice on the altar of public relations” a senior official who had done nothing wrong.
Lord Justice Sedley referred to the fact that such blame as the Healthcare Commission report allocated was subsequently accepted by the board members of the Trust, all of whom resigned following publication of the report. There had been no good reason, therefore, to dismiss the Chief Executive.
The money spent on compensation and costs could have been better utilised in improving hygiene and patient care in hospitals. The Court went to allow the appeal.
Reference: [2010] EWCA Civ 678

With changes emerging as to how Revenue focuses on locums, tax expert Geraldine Corcoran looks at the continued uncertainty over the issue facing the medical profession

In a previous article for Irish Medical Times earlier this year
(February 12, 2010, see
www.imt.ie/opinion/2010/02/assessing_future_tax_implicati.html),
I outlined the tests that would be of assistance to practitioners in determining the employment status of locums whom they engage.
This matter came to the fore following the Appeal Commissioners’ decision in favour of Revenue in the MIDOC appeal, i.e. that the locum service provided was in the nature of an employment. It was hoped that the appeal against this decision to the court would provide some clarity in this area. However, that case was settled out of court and it is understood that a financial settlement was reached between the parties involved.
This is unfortunate, as in the absence of a court ruling on the facts, the area remains unclear for locums and practitioners. However, it is important for practitioners to be aware that this does not mean that all locums will now, automatically, be treated as PAYE taxpayers.
Revenue must still have regard to the Code of Practice for Determining Employment or Self-Employment Status of Individuals and also relevant case law. They have stated in a recent tax briefing:
“The code does not espouse a ‘one cap fits all’ approach, but rather stresses that ‘it is important that the job as a whole is looked at, including working conditions and the reality of the relationship when considering the guidelines. The overriding consideration or test will always be whether the person performing the work does so as a person in business on their own account’.
As stated in the Code of Practice –
l Its purpose is to eliminate misconceptions and to provide clarity, and;
l It is not meant to bring individuals who are genuinely self-employed into employment status.”
However, we understand from the relevant professional bodies that, in most cases, Revenue is taking the view that medical locums are employees. Because this does not reflect the economic reality for a number of genuinely self-employed locums, it is only a matter of time before this approach will give rise to further appeals on the issue.
Meanwhile, practitioners do need to review their engagements, both past and present, to ensure that they are tax compliant. Where practitioners are engaging individuals, it is their responsibility to correctly determine the employment status of that individual. Locums must also know the capacity in which their services are engaged.
The guidelines concerning the Code of Practice for Determining Employment or Self-Employment Status of Individuals can be used as a checklist to assist in determining the status of each locum (see www.revenue.ie).
Practitioners must then consider all the factors that are present in or absent from each case, listing separately those that point towards employment and those that point towards self-employment, and then examine the overall picture that emerges.
It is recommended that practitioners carry out this review in conjunction with their professional advisors and, if possible, the locums themselves.
When the review has been carried out by practitioners, it may become clear that the locum should in fact be treated as an employee based on the facts. In that instance, the position should be regulated with Revenue without delay. Practitioners’ professional advisors will be able to explain the benefits of making a voluntary disclosure to Revenue in this instance. Revenue will, most likely, seek to backdate taxes due in relation to the engagement of locums by practitioners.
However, where locums have been fully tax compliant as self-employed individuals, it may be possible for the employer to negotiate with Revenue to reduce the effect of such backdating, where it can be shown that there was no loss of revenue to the Exchequer. Again, this would depend on the background to each case, and each doctor’s professional advisor will be able to guide them in this regard.
If it is clear to practitioners and their advisors, on the facts, to support treating the locum as self-employed, I would recommend the following action:
l A detailed report should be compiled, setting out the reasons it is believed the locum is self-employed;
l Provide back-up documentation where relevant;
l While the existence of a contract will not determine self-employment, once the facts support it, a well-drafted consultancy agreement between the practice and the locum, which sets out clearly the self-employed nature of the relationship, may be advisable;
l Apply, in writing, to your local Revenue office for a formal determination of the employment status of the locum.
This will eliminate the risk of having the tax treatment challenged at a later date by Revenue and provide clarity and certainty. However, if the Revenue reverts to practitioners with a determination that the locum is an employee and practitioners are still strongly of the opinion that they are self-employed, then a request should be submitted to Revenue for its detailed reasoning in support of its view.
It is important for practitioners to be aware that it is not the end of the road if Revenue disagrees with them. Tax law is enacted by the Oireachtas and clarified by the courts, in case law, where there is ambiguity. Every taxpayer has a right to seek a review of a decision made by a Revenue official concerning their tax affairs and there is an option to have this review carried out jointly by Revenue’s Internal Reviewer and an External Reviewer.
However, if the difference of opinion between Revenue and the taxpayer is on a point of law, the reviewers will only intervene where they consider that the Revenue opinion is clearly incorrect. If practitioners are still dissatisfied with a decision made by Revenue then, under Irish law, there is an appeal process to review a taxpayer’s affairs.
The Appeal Commissioners are an independent body and are responsible principally for the hearing of appeals by taxpayers against decisions of the Revenue Commissioners.
l Geraldine Corcoran, A.I.T.I., T.E.P,
P. Ryan & Co. Chartered Accountants,
4th Floor, Harmony Court,
Harmony Row, Dublin 2.
Tel: 01-6311200/Fax: 01-6311250
e-mail: geraldine.corcoran@pryan.ie
www.pryan.ie

Continuing our series on the Irish Healthcare Awards, Valerie Ryan looks back at how, for the first time in Ireland, an entire hospital campus was declared smoke-free

A third major hospital has just gone entirely smoke free, banning patients, visitors and staff from lighting up anywhere on its campus.
The Mater Hospital joins St Vincent’s University Hospital (SVUH) and Connolly Hospital in Dublin, and also Cork University Hospital (CUH) in imposing a smoking ban on its grounds.
In January 2009, St Vincent’s became the first Irish hospital to introduce a smoke-free campus policy, followed by Connolly Hospital in Blanchardstown in May 2009.
Then in June this year, CUH followed to become the first hospital outside of Dublin to declare itself a smoke-free zone following the introduction of a smoking ban for patients, visitors and staff on the hospital campus.
The latest hospital to go smoke-free was the Mater on July 1 — and more are due to follow suit over the next five years.
The Department of Preventive Medicine at SVUH received so many calls enquiring about its initiative and the implementation of the policy, that it organised a training day on September 14 last year to share its approach. At this stage, there are more hospitals planning to come on board.
The lead shown by St Vincent’s was recognised at last year’s Irish Healthcare Awards, when the smoke-free project took home the award for Best Public Health Initiative.
The 2009 Irish Medical Times Healthcare Award — presented for the ‘Implementation of the first smoke-free hospital campus policy in Ireland at St Vincent’s University Hospital’ — “validated the good work that was done and helped in raising the profile” of the project, explained Health Promotion Co-ordinator at SVUH, Denise Comerford.
Six years ago, Ireland became the first country in the world to introduce a law banning smoking indoors in workplaces, but no health services opted for a smoking ban both indoors and outdoors.
Uncharted territory
Instead, a certain level of smoking was tolerated — facilitated by outdoor, open structures or bins at doorways. As Prof Cecily Kelleher and colleagues at SVUH and UCD explained in a published review of the implementation of the policy, it was felt to be uncharted territory, as public acceptance of the indoor ban had not been tested.
Secondly, there were compassion and civil-liberties issues to be addressed for patients, particularly whether smokers had a right to smoke outside when in hospitals. Thirdly, the implementation process had not been tested.
The smoke-free policies introduced across hospital campuses have involved long-term and step-by-step planning measures. The SVUH and UCD group say the process put in place to reach the point where an outright ban could be declared was lengthy and extensive, but necessary.
The St Vincent’s project was achieved by firstly setting up a steering group to develop a smoke-free campus policy and direct the implementation plan for January 1, 2009. The policy was communicated to all patients, staff and visitors over a six-month period from June to December 2008.
Nicotine replacement
Support was offered to staff and to patients who wanted to quit or manage their smoking — while at work or while as an inpatient — through the smoking advice service and free nicotine-replacement therapy (NRT).
Training was offered from June 2008 to February 2009 to clinical staff on how to manage patients who smoked and on dealing with difficult case scenarios. And finally, an observational audit of the grounds was carried out to assess compliance with the policy from January to March 2009.
The Department of Preventive Medicine and Health Promotion had been carrying out surveys on the prevalence of smoking among patients and staff since 1997. In the 2006 survey, it found that the majority of patients and staff agreed with the introduction of a campus-wide smoking ban. More recently, a survey was carried out at one year post-introduction of the smoke-free campus, in March 2010.
Extensive information will be available on completion of the data analysis, on smoking prevalence, attitudes of patients and staff to the policy and general compliance. It is expected this information should be available in September.
Smoke-free
On average, 2,500 people pass through the hospital every day and an estimated 725 of these are smokers. A patient information leaflet was developed to inform patients that the hospital was going smoke-free from January 1, 2009 and included information on NRT and support services available in the hospital and the community.
This was sent with appointment letters and the policy was relayed through the patient handbook, signage, digital TV system and recurring audio announcements at all main entrances. They also made sure to inform local services in the catchment area such as GPs, pharmacies, fire brigade and ambulance services.
Staff were informed of the policy through a series of measures – awareness and education sessions on each ward for nursing staff and healthcare assistants; local department meetings; and presentations at heads of department meetings.
All available existing lines of communications were used, such as newsletters, user emails, notice boards, stands, signage and hospital intranet.
A written protocol for managing patients who smoke at the time of admission was developed and circulated to all wards. A support structure for patients and staff who smoke, and for staff dealing with patients who smoke, was also put in place.
Patient referrals to the smoking advice service increased between January and February 2009.
Staff referral levels increased, reaching peak levels in December 2008 and January 2009. Units of NRT prescribed multiplied eightfold in January 2009 compared to January the previous year. However, this is returning to previous levels.
Litter free
After the introduction of the smoking ban, an audit showed high compliance by patients, staff and visitors. The visibility of litter decreased, as well as litter from cigarette butts. Smoking-related written report incidents peaked in January but in the months following the introduction, they declined.
Irish Medical Times is looking to hear from anyone who has identified a potential idea in the past year and developed a project aimed at improving the delivery of healthcare.
The entries in the Irish Healthcare Awards are judged by an independent panel of experts who look for ideas that solve problems in the health service, bridge gaps and improve patients’ lives.
“We are looking for projects and initiatives that demonstrate originality, innovation and excellence,” said IMT’s Dylan Conway.
l For further information on any aspect of the 2010 Awards contact Dylan at Tel: (01) 8176330 or email: dylan.conway@imt.ie