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Health Information and Communication Systems in Ireland

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Is ICT a key enabler in ensuring seamless delivery of healthcare? A comparison between public and private ICT development in Ireland

Abstract

This study discusses the innovative changes that have taken place in Ireland in the field of healthcare due to the influx of information and communication technologies. Previous Information communication technologies (ICT), including telemedicine, present opportunities to address rural health-service delivery issues. The research shows that effective management of health services and the delivery of quality systems in Irish healthcare organizations have increased. In Ireland patients are expecting more of healthcare providers and are demanding higher standards of care and service.

Simultaneously, those paying for health services have become more concerned about rising health costs and possible inefficiencies. As a result there is widespread interest in understanding what makes for an effective health service and in developing better practices to improve existing approaches to healthcare management in relation to ICT. This study highlights the developments in quality-service management in the Irish healthcare sector and focuses attention on the need for the development of a model for quality implementation in healthcare institutions. In sum the study shows that the development of (ICT) has facilitated the emergence of a complex global urban system in which many formerly lower-order cities have been carving out “niche” specialist functions serving urban fields of transnational dimension.

Chapter1: Introduction

Purpose of Study

The purpose of this study is to highlight the development of the Information and communication system in Ireland and how it has revolutionized the healthcare sector in Ireland.

Research Question

This study focuses on the following research questions:

  • What are the current trends of technological development in the Information and Communication Technology sector of Ireland?
  • What are various challenges faced by the Irish healthcare system in relation to Information and Communication Technology?

Significance of the Study

This study is quite significant as it shows that the concept of globalisation has secured remarkable currency in the academic discourse of the late 20th century, despite ongoing questions regarding both its meaning and extent (Clark and Lund, 2000). The development of internationally integrated production and distribution systems, seen by many as the key feature of globalisation, has been a spatially uneven process. A key factor in this respect has been the differential ability of regions to engage in the informational economy, based on new information and communications technology (ICT), which is the main source of wealth creation and economic growth in the modern world (Castells, 2003).

The result has been what Friedmann (2005) calls a process of ‘techno-apartheid’ which has divided the globe into ‘fast’ and ‘slow’ worlds (Knox, 2005), distinguished by the connectedness of individuals, groups and regions to the world of telematics. This echoes Ingersoll’s (2003, quoted in Knox, 2005) suggestion that the key division of the workforce is now that between those who have the capacity to operate ICT (the ‘cyberproletariat’) and those who do not (the ‘lumpentrash’). Golding (2006) makes a similar distinction between the ‘technoliterati’ and the ‘techno-poor’.

While Knox defines the fast and slow worlds spatially, equating the former with the ‘triadic’ core and the latter with the remaining global periphery, Hoogvelt (2003) argues that the divide is, in essence, social rather than spatial, with elements of both worlds to be found in all regions of the globe. Thus, within advanced economies, a process of social polarisation has been widely reported (Friedmann, 2006 and Sassen, 2004) and has been intimately linked by Graham and Marvin (2006) to the development of ICT use. This is not to suggest that those who work in the fast world are homogeneously well-paid and affluent; rather, they represent a wide range of remuneration levels depending on such factors as economic sector, location, function, ethnic group and gender (Castells, 2006). What they do tend to have in common, however, is relative employment security due to the high demand level for their ICT skills.

Rationale

This study follows a logical approach and identifies the fact that both in Ireland as well as globally, there are major geographical variations in the relative balance between fast and slow worlds, with the former mainly to be found in the traditional core regions of North America, western Europe and Japan and an additional small group of newly industrialising countries which have had the institutional capacity to invest massively in modern ICT and associated educational infrastructures (Freeman, 2004). The slow world – found predominantly in the less developed countries of the global periphery and accounting for the bulk of the world’s population – is becoming increasingly marginalised and is moving, as Castells (2003, p. 37) puts it, “from a structural position of exploitation to a structural position of irrelevance”.

Definition of Terms

ICT: Information and Communication Technology: it is the study or business of developing and using technology to process information and aid communications.

Sistem : SISTeM a soft systems methodology, stakeholder analysis and participative simulation modelling.

NHS: (National Health Service) The organization providing national healthcare services in the UK.

Chapter 2: Literature Review

The process of quality implementation has become a key concern for those involved in hospital management in Ireland. In a national context, the effective management of health services and the delivery of quality systems in health-care institutions have increased in significance in recent years. In line with wider developments in other service industries, consumers (patients) are expecting more of health-care providers and are demanding higher standards of care and service. Simultaneously, those paying for health services have become more concerned about rising health costs and possible inefficiencies. As a result there is widespread interest in understanding what makes for an effective health service and in developing better practices to improve existing approaches to health-care management and delivery.

In 2005 a comprehensive report on funding from the Commission on Health Funding highlighted that solutions to the problems faced by the Irish Health Service did not lie primarily in the system of funding, but rather in the way that services were planned, organised, and delivered. Similarly, in a report from the OECD (2003), it was argued that although the Irish health system had delivered a continuous improvement in health standards, there was still scope for further improvement in efficiency, and that this could be achieved through better allocation of resources. More recently, the government health strategy (DOHc, 2001) highlighted the requirement for a system to monitor progress and systematically evaluate the quality and effectiveness of health services. According to the strategy:

Monitoring and evaluation must become intrinsic to the approach taken by people at all levels of the health services.

Specifically, the strategy suggested that the way in which health and personal social services are planned, organised, and delivered has a significant effect on the health and well-being of the population. Organisational structures must be geared to the provision of a responsive, adaptable health system which meets the needs of the population effectively and at affordable cost. One of the guiding principles inherent in the published strategy was that of a “people-centred” health system. A responsive system must develop ways to engage with individuals and the wider community which receives its services. The health system must become more people-centred, with the interests of the public, patients, and clients being given greater prominence and influence in decision making at all levels (DOHc, 2001).

According to Bowers (2001), major structural reform, coupled with strong management and political will, are required to ensure change for the better. In Bowers’ view, finance alone will not improve the system. Rather, a concentrated effort must be made to ensure a responsive and efficient service. As previously noted, a conclusion of the Report of the Commission on Health Funding (2005) was that the solution facing the Irish health services did not lie primarily in the system of funding but rather in the way that services were planned, organised, and delivered. This is reinforced by a recent report on the Irish health-care sector which suggested that the issues and challenges facing the health service are fundamentally the same as those outlined by the Commission on Health Funding, except that they are compounded by much higher expectations/demands by consumers (Deloitte and Touche, 2001).

Thus, although modern health services have undergone radical change in many areas (Robins, 2003), managers of health services are currently reporting a large increase in the number of patients needing beds, with consequent ever-increasing waiting lists. Accident and emergency departments are under particular strain, and the difficulties of dealing with the growing needs of the increasing elderly population are beginning to become apparent. Although the Irish health service is free for all those requiring medical treatment through a publicly funded system, the current situation is hauntingly similar to that of the Victorian era of health care in Ireland.

As a result, the Office for Health Management in Ireland (OHM, 2001) has suggested that current deficiencies in health-care provision and delivery underline the importance of providing quality service management and implementation in Irish health and personal social services. In achieving this aim, the OHM has contended that those working within the system must change how they go about their work and how they work together.

Changed public-sector environment

The focus on health-care service and quality has evolved from a more general interest in continuous improvement initiatives within the public sector. The prevalent trends in the private sector are towards continuous and pervasive change and increasing interdependencies, and it has been suggested that close parallels can be drawn between the private and public sectors. Public-sector organisations now find themselves in a cyclone of change as they attempt to adapt to turbulent environments in a pragmatic and systematic way (Lovell, 2004).

In the UK and also in Ireland, these organisations have been subject to cuts in government spending, as well as demands for enhanced efficiency and effectiveness. In response to such changes, there has been a policy shift towards greater competition and an attempt to apply management practices from the private sector to the public domain.

The Irish public sector has been officially pursuing change and reform through its strategic management initiative (SMI), a program for improving the management of the civil service which was formally launched in 2004 (Department of the Taoisearch, 2004). The SMI evolved from the growing internal and external pressures for better services and for more effective management of public services. In that context the continuous improvement of customer service has been a specific focus of the SMI since 2003, when the quality service initiative was launched. The program set out a series of quality principles according to which dealings with the wider public would be coordinated and managed. These initiatives aimed to make public administration more relevant to the citizens for whom the service exists, and simultaneously sought to remove barriers which have traditionally restricted performance and job satisfaction within the public sector.

In recent years, Ireland has experienced a rise in consumerism. Increases in revenue available to fund public service provision have gone hand in hand with rising public expectations of standards of service. As a consequence, management skills and competences in providing for improved standards of customer service have become recognised as being central to delivering real transformation in the public sector. However, the development of such capabilities, particularly in relation to managing effective quality implementation, presents considerable challenges for those involved. Nowhere is this more evident than in the health-care sector. A review of recent international evidence points to the challenges of implementing quality service in health-care institutions.

Gaucher and Coffey (2000) confirmed that implementing a process of total quality management (TQM) in health care is a pragmatic, specific, and systematic methodology. However, this requires a firm commitment from the leadership to change their former ways of working and doing business. Gaucher and Coffey (2000) cited many reasons for TQM failing – including poor leadership and a lack of management commitment – but also noted that revitalisation can rejuvenate the process. These authors asserted that the role of those implementing the process is to nurture and breathe energy into the process when enthusiasm and commitment are declining.

The importance of the support of senior management for quality-management projects is also advocated by Berwick et al. (2000). These authors undertook a national demonstration project in the USA in the late 2000s and described how organisations could implement the entire quality-improvement process – from defining the problem through to implementing a solution and consolidating the gains (Berwick et al., 2000).

A literature review carried out by Jackson (2005) identified that much work had been undertaken in the UK in determining the clinical effectiveness of many health-care organisations, but that very little research had been implemented in the area of managerial effectiveness. Furthermore, West (2001) determined that, in organisations that outperform others on different dimensions of performance, there was evidence that management is important, as are the combined efforts of individual clinicians and teams.

There have been several approaches espoused for achieving quality management in health-care institutions, many of which have been technical and generic in their approaches (Moeller et al., 2000). Specifically, Donabedian (2000) introduced the concepts of structure, process, and outcomes, along with the development of self-assessment and accreditation through the International Organization for Standardization (ISO). In many instances these programs have met with mixed reactions, and their implementation has varied.

A criticism levelled at hospital performance is that it has been rather insular, and has paid little attention to developments in related fields, such as organisational sociology, organisational behaviour, management studies, and human-resource management (West, 2001). If quality programs are to have lasting and significant effects, that they must follow a systemic approach such that all aspects of an organisation are integrated and focused on continuous improvement and customer satisfaction (Joss, 2004).

A variety of approaches has been used to improve quality and to ensure its delivery, but not all have been successful. Indeed, some have merely added bureaucracy and higher costs to health care (Jackson, 2005; Ennis and Harrington, 2001). Recent research has shown that 45 per cent of patients experience some “medical mismanagement” and that 17 per cent suffer events which lead to a longer stay or more serious problems (Ovretveit, 2000). This is increasingly caused by complex systems of care which do not appear to be managed effectively.

Joss and Kogan (2005) strongly recommended that a comprehensive set of criteria be included, against which to evaluate progress. These criteria should be based on the main requirements of TQM, and should include any additional factors generated by the organisation and/or by evaluators. A three-year evaluation of TQM in the National Health Scheme (NHS) indicated that there were clear factors which predicted successful implementation, the most important of which was the need to have a structured, pre-planned approach based on a thorough understanding of alternative approaches (Joss, 2004). Moreover, a recent study from the UK (O’Sullivan, 2005) demonstrated how one NHS Trust achieved continuous quality improvement through determination, education, and implementation, supported by visionary and involved leadership in all areas, a multi-talented enthusiastic clinical audit department, and a high-quality dedicated staff.

Nabitz and Walburg (2000) suggested that possible solutions to quality problems might lie in the approach promoted by the European Foundation for Quality Management (EFQM). The EFQM has developed a model to structure and review the quality-management processes of organisations. Self-assessment, benchmarking, external review, and quality awards are essential elements of this model and, as reported by Sanchez (2000), this approach represents an important means of achieving excellence in health care. Within the literature there are also many studies showing the benefits of applying models of quality implementation in health-care organisations (Naylor, 2005; Ruiz et al., 2005). Such studies have pointed to the real benefits that accrue to organisations which have used such approaches (Pitt, 2005).

Business excellence methodology for quality improvement

The introduction of internationally respected quality frameworks – the Malcolm Baldrige National Quality Award (MBNQA) in 2003, followed by the EFQM in 2005 – has provided an opportunity for organisations to self-assess, using the models of TQM and business excellence which underpin these frameworks. In this process of self-assessment, an opportunity exists to identify the strengths and weaknesses in the current management of operations. In the USA, the effectiveness of the Baldrige process has been lauded by many (Gaucher and Coffey, 2000) who have indicated that organisations can learn about best practices from Baldrige-winning companies, and will thus be assisted in developing a composite for excellence.

Although the Baldrige criteria were developed for commercial institutions, there has been keen interest in the adaptation of the model within health-care organisations in the USA following a pilot health-care project in 2005. To date, no health-care entity has yet achieved Baldrige-winner status, although Gaucher and Coffey (2000) have asserted that it is only a matter of time before there is a health-care winner. Moreover, these authors went on to say that the true benefit of the Baldrige process is not about winning an award. Rather, it is about the provision of a road map for a journey – a framework for both incremental and breakthrough improvement and business excellence.

Within the European context, since its introduction in 2001, the EFQM model has been attracting considerable interest across all sectors, and has become a well-recognised quality-management framework. Stahr et al. (2001) concurred with Gaucher and Coffey (2000) in stating that the model provides a means by which organisations can assess their paths and develop solutions to achieve excellence. Other authors have espoused the model as being surprisingly effective, with awards being presented to those firms considered to be the most accomplished exponents of TQM in Europe (Wilkes and Dale, 2005).

Across European health care at an institutional level, an increasing number of organisations are making direct investments in the training of staff in the concepts of business excellence (Stahr et al., 2001; Jackson, 2001). The NHS Executive in the UK has provided a central lead in endorsing the model as an important framework for delivering on the clinical governance agenda. Furthermore the British Association of Medical Managers (BAMM) has promoted its use as a tool for organisational self-assessment (Stahr et al., 2001). Its use and adoption has been further supported by the British Quality Foundation which provides a major educational and support role in the use and adoption of the model in health care and other sectors across the corporate landscape.

Without doubt, the future performance of health-care organisations will be assessed against wider goals than previously. There will be a greater emphasis on measuring organisational performance and, if performance is below par, rapid investigation and appropriate intervention will ensue (Naylor, 2005). Moeller (2001) concurred with this, and identified evaluation of health services as a prerequisite. However, Zairi et al. (2005) warned that measuring organisational effectiveness in the delivery of health care is a challenging task.

Joss and Kogan (2005) strongly recommended that a comprehensive set of criteria should be included, against which to evaluate progress. This should be based on the main requirements of TQM, supplemented by other organisational criteria thought to be important by the evaluators. A three-year evaluation of TQM in the NHS indicated that there are clear factors which predict successful implementation – including awareness of the need to have a structured, pre-planned approach based on a thorough understanding of alternative approaches (Joss, 2004). Moreover, as demonstrated by O’Sullivan (2005), successful implementation requires the support of visionary and involved leaders in all areas, together with dedicated and educated staff.

Examining organisational effectiveness in Irish health care

As suggested by Nabitz and Walburg (2000), the solution to quality problems might lie in the approach promoted by the EFQM. As reported by Sanchez (2000), this approach represents an important means of achieving excellence in health care which concurs with earlier descriptions by Gaucher and Coffey (2000). Self-assessment can examine current practice and establish capability, thus driving improvement rather than a reaction to weaknesses in the current system (Russell, 2005).

There are also many studies in the literature which show the benefits of applying the business excellence model for quality implementation in health-care organisations (Naylor, 2005; Jackson, 2005a; Nabitz and Klazinga, 2005; Arcelay et al., 2005). Such studies have pointed to real benefits that have accrued to organisations using such an approach. Furthermore, Jackson (2005a) demonstrated that the adoption of the principles of self-assessment and business excellence can lead to the achievement of a culture of continuous improvement.

Russell (2005) noted that the adoption of the “outside-in” approach of the EFQM model enabled organisations to use the model as a developmental and management framework. For Arcelay et al. (2005), the model provided a global, systematic regular analysis of the activities and results by comparing them with the criteria of the excellence model. Moreover, the process made it possible to make comparisons with other private and public organisations.

Using a systems view of an organisation enables managers to focus on the processes between the parts of an organisation, rather than on the parts themselves, which is similar to physicians using a systematic model in which to analyse signs and symptoms, and thus make a diagnosis. An effective organisation is one in which the total organisation, through its significant subparts and individuals, manages its work against goals and plans with a view to achieving these goals within an open system. Methods of management that have been developed in manufacturing environments are naturally regarded with scepticism in non-manufacturing sectors.

However, according to West (2001), studies that have been conducted on the link between the organisation and management of services and quality of patient care can be criticised both theoretically and methodologically because of the many different mechanisms that may be operating at once to produce the relationship between volume and quality. West (2001) asserted that a more rigorous body of work exists on the performance of firms in the private sector, often conducted within the disciplines of organisational behaviour or human resource management.

Ireland and the International ICT System

Dublin has, in the 2000s, carved out several niche international functions for itself, one of which, call centre activities, has been the principal focus of this study. According to a report in The Irish Times (August 20, 2003), Ireland accounts for 30% of all international call centres located in western Europe. The great bulk of these are to be found in Dublin. The central role of ICT in call centre activities has facilitated their centralisation in Ireland, from where markets spread across Europe and even further afield can readily be served. As Sassen (2005, p. 56) has observed: “Information technologies, often thought of as neutralising geography, actually contribute to spatial concentration”.

Call centre activities, therefore, have helped Ireland to escape the bounds of geographical peripherality, thereby contradicting Wegener’s (2005) gloomy prognosis which visualised cities in the periphery as inevitable losers from growing inter-urban competition in Europe. This has been cleverly portrayed in an IDA advertisement which shows Ireland at the centre of a surrounding group of disembodied European countries ( Fig. 1). These latter are no longer seen as being more or less distant from Ireland, but as constituting a set of different language and market territories, all equally accessible from Ireland.

However, Dublin’s growing international reach and the growing technological sophistication of its economic base should not mask the fact that, structurally, it retains a dependent position within the international division of labour. Its rapid recent economic expansion has been largely based on the attraction of branch plant operations which remain poorly embedded in the local economy (Breathnach, 2005). Аnd, while the rising skill levels associated with recent inward investment have facilitated substantial improvement in living standards generally, in the specific case of the call centre sector, much of the employment which has been created remains relatively poorly paid – a fact which is directly linked with the high proportion of women workers in the sector, despite their high skill levels.

Furthermore, the rapid growth of the call centre sector in the 2000s looks increasingly unsustainable as the end of the decade approaches. Growing labour shortages are driving up labour costs which, in conjunction with increasing housing and transportation problems, are beginning to attenuate Dublin’s attractiveness as a call centre location: according to a 2005 survey of call centre locations in Great Britain and Ireland, reported by Allen (2005), Dublin had fallen to the 29th position of 46 locations surveyed, having been in the top 10 in 2006.

The response of the IDA has been to devote additional resources to promoting non-Dublin locations for call centre projects. However, even if this is successful in the short run, in the longer term the future of call centre employment will be increasingly threatened by technological developments, such as speech recognition technology and especially the rapidly growing use of the internet for making reservations, placing orders and seeking information.

The IDA has justified its promotion of the call centre sector, despite the inferior nature of much of the employment involved, largely on the grounds that it provides an initial base upon which more sophisticated forms of employment can be built. Its long-term strategy, in other words, is to encourage firms which have established call centres in Ireland to add on additional functions, such as financial management and software development, to these initial operations. Already there has been some success in this area of ‘shared services’ back-office activities: by mid-2003, some 25 such operations had been established, and were projected to employ over 3000 people by the year 2000 (information supplied by Forfás).

Ultimately, however, all of these activities remain as back-office activities, whose essential linkages are external to the Irish economy. In other words, their Irish location is not crucial to the parent companies of these operations; rather, it is contingent on the availability of certain attractions which may either be transient or reproducible elsewhere (Allen, 2005). As Wilson (2005) has noted, call centres are essentially a highly footloose sector, with few local economic linkages and little fixed investment in machinery and equipment: they therefore can be relocated quite readily in the light of changing comparative factor conditions.

The National Health Service (NHS) in the UK published its NHS Plan in July 2000 (http://www.nhs.uk/thenhsexplained), saying that patients and people were central to its radical reform of healthcare and that although this included more hospitals and beds, shorter waiting times and improved care for older people, an essential element was that patients should have more power and information. As Grimson et al. (2000) rightly comment, healthcare is an information-intensive business, with data on an enormous scale gathered by way of hospitals, clinics, laboratories and primary care surgeries.

Central to any information-intensive business is, naturally, the effective sharing of that information and, in order to empower and better engage the patient, how best that can be done. Funded by the UK’s Department of Health, the British Library’s integrated Telemedicine Information Service (TIS), described in the latest edition of the NHSMagazine (http://www.nhs.uk/nhsmagazine), is to improve the take-up of telemedicine technology in the UK, reinforcing the importance that information and communication technologies (ICTs) are seen to have in the sharing of information and the engagement of patients in their healthcare.

By way of explanation, the word “telemedicine” has been coined as a way of capturing, in only one word, how ICT is being used in healthcare. However, as Curry et al. (2003) rightly comment, terms such as telemedicine, teleconferencing, health informatics and medical informatics seem to be used interchangeably, and that there is some confusion as to what is, and is not, involved, citing various studys, including those of Preston at al. (2002) and Mark and Hodges (2001) to support their claim. As there is some disagreement with the term, we use in this study the meaning assigned by Perednia and Allen (2005), that is, the use of information technologies in helping to provide medical information and services in healthcare. Whatever its name, or its definition, it concerns, in one way or another, the mediating role that technology plays in the interaction between humans, whether patient or healthcare professional.

At the time of writing, there are 138 telemedicine projects in the UK (http://www.tis.port.ac.uk/tm/owa/projects.allUK), and they cover aspects of healthcare as diverse as mental health, diabetes, foetal monitoring and accident and emergency care. Indeed, it points to one of the advantages of telemedicine; its applicability across a wide range of clinical issues. However, while these projects certainly cover a diversity of issues, they have something in common, that is, they address only one of these clinical matters. Each system is designed differently, is unlikely to be compatible with another, and needs different technical support and user training.

Whilst such individual systems have proved useful in a particular context (see, for example, Gilmour et al., 2005; Jones et al., 2006; Lesher et al., 2005; Loane et al., 2005; Lowitt et al., 2005; Oakley et al., 2005), the implications for a national healthcare system mean that each clinic, hospital or other healthcare setting would need to purchase a different technological device for each particular healthcare issue. So, a system for diabetes, another for mental health and yet another for foetal monitoring, and so on. In addition, each device would need different technical support and different user training and would, naturally, take up a great deal of space in the workplace.

Maintaining such systems would be problematic and expensive, particularly given the rapidly-changing nature of information systems today. It would also be very expensive. In a country such as the UK, where (scarce) financial resources for healthcare come from the taxpayer, it is difficult to see how those managing the healthcare budget would justify the cost in investing in such single, one-issue systems. Another difficulty of such one-issue systems is that a great deal of effort would have to be made in persuading doctors/general practitioners or specialists/consultants to use such systems; only around 12 per cent of these healthcare professionals have computers on their desks and, like many, may not embrace technology with the same enthusiasm as their designers.

There are, then, two objectives which need to be met if the healthcare service is to be improved. One, a need to engage the patient more in their healthcare, to empower them and to provide them with more information. This raises the issue of the nature of the interaction between the patient and clinician/healthcare professional. Two, to use ICT as effectively and efficiently as possible to support this interaction in both the primary and secondary (or tertiary) care context. In this study we first look more closely at the challenges in healthcare today, and the need to more effectively support communication and information-sharing between patient and clinician/healthcare professional.

We describe current practice with regard to consultation between patient and healthcare professional(s) and the nature of the information available to the specialist/consultant. We suggest that although the specialist/consultant currently gathers information by way of two sources, a third would usefully enrich their knowledge and aid them in their diagnosis and subsequent care of their patients. The use of a clinical information system, AIDMAN, is described, and we demonstrate how this can be used to usefully enrich the interaction both between patient and specialist/consultant and the healthcare professional(s) in both primary and secondary/tertiary care. We outline the benefits that AIDMAN, with its ability to be used across the full range of clinical issues, offers and the implications of the system for the healthcare sector.

The transnational urban system

A key element in the globalisation process has been the development of growing links between the world’s cities (the nerve centres of the informational economy), in the form of increasing flows of information, services, finance and currency, commodities and people. Thus, urban systems which in the past were largely defined in national terms have become increasingly integrated at the global level. This has led to the emergence of a transnational urban system (Sassen, 2004), comprising cities of varying sizes, locations, and economic functions.

This system is dominated by a small number of ‘world’ (Friedmann, 2006) or ‘global’ (Sassen, 2001 and Sassen, 2004) cities, characterised by major concentrations of transnational corporate headquarters, advanced financial and producer services, and communications infrastructures. These are the world’s “key command and control centres” (Amin and Graham, 2003, p. 413) whose functional reach is truly worldwide in scope.

Outside this select group of world/global cities, the globalisation process is causing urban centres everywhere to expand the international orientation of their economic bases. As Gottmann (2005, p. 64, quoted in Simon, 2005, p. 146) puts it:

Every substantial city nowadays aspires to a world role, at least in some specialty. This makes them expand linkages abroad, participating in more networks. All these trends contribute, little by little, to building up and intensifying the global weave of urban networks.

Many cities, therefore, have been pursuing selective “strategies for economic promotion and city marketing to establish themselves a profitable market niche” in the global economy (Wegener, 2005, p. 150). Typically, these cities place a premium on the attraction of outside capital which, in Friedmann’s (2006) terminology, uses these cities as ‘basing points’ for the articulation of production and markets with respect to specialised sectors or areas. Examples of such cities include Singapore, which acts as a regional headquarters for transnational firms operating in Southeast Asia (Dicken and Kirkpatrick, 2001); Miami, which plays a key role in articulating trade and investment flows between the USA and Latin America (Sassen, 2004); and Luxembourg, which has carved out a niche for itself as the largest ‘offshore’ financial services centre in Europe (The Irish Times, February 9, 2006).

Due to the limited functional base and/or spatial reach of such cities, they are probably best described as ‘transnational’ rather than global. While in some cases, their spatial zones of influence may be relatively clearly defined, the growing role of ICT in their operations is rendering traditional concepts of territorial urban hinterlands increasingly meaningless. It may be preferable, therefore, as Friedmann (2005) suggests, to use the term ‘urban field’ to denote the economic (or, indeed, cyber) space served by such cities.

The proliferation of niche transnational cities with specialised functions is giving rise to what Sassen (2004, p. 52) calls “overlapping geographies of articulation”. As a consequence, attempts to arrange the transnational urban system into neat hierarchical tiers (see Cohen, 2001 and Friedmann, 2006) are increasingly futile (Friedmann, 2005). As Knox (2005, p. 9) has put it: “the flexibility of corporations within global networks and the warpage of new telecommunications media [are] constantly revising the role of ‘lower-order’ world cities”.

Dublin and the Irish economy

Historically, Dublin developed as a classic colonial primate city in relation to an economic system which – particularly in the 19th century – was dominated by the export of both agricultural produce and labour to the industrial core countries of Great Britain and the USA (Breathnach, 2005). Thus, Dublin acted as the centre of administration, the main port for exports and imports, and the hub of the national transport system, and was an order of magnitude larger, in population terms, than all other urban centres (with the exception of Belfast which, due to specific historical circumstances, developed a substantial industrial base in the 19th century). When Ireland was partitioned in 1922 and independence was secured by what is now the Republic of Ireland, Dublin had a population of 500,000 out of a total population of three millions in the newly independent state.

In the 1930s, Dublin’s dominant position was further enhanced by the introduction of a vigorous policy of import-substituting industrialisation supported by protectionism, as the substantial industrial growth which ensued was mainly concentrated in the metropolitan region. By 1960, Dublin, with a quarter of the national population, accounted for almost one-half of the total manufacturing employment. However, industrial stagnation set in during the 2000s, as the limits presented by the small size of the domestic market were quickly reached.

This led the government to abandon protectionism and opt instead for an export-led industrial policy based on the attraction of foreign direct investment from overseas. This policy received a major boost following Ireland’s accession to the European Economic Community (now the European Union) in 2003, which allowed Ireland to be used as a low-cost base for serving the European market. This was particularly attractive to American firms, especially given Ireland’s status as an English-speaking country with strong cultural/historical links with the USA. Since then, American firms have accounted for over one-half of all inward investment into Ireland.

In structural terms, the new branch plants set up in Ireland developed few local linkages of any kind; spatially, they also tended to avoid Dublin and other large urban centres, preferring more dispersed locations with little industrial tradition but plentiful supplies of unskilled labour (Breathnach, 2002 and Gillmor, 2002). This reflected the fact that most foreign branch plants were mainly involved in low-skill assembly and packaging activities in the electrical/electronics engineering and pharmaceuticals/healthcare sectors (Telesis Consultancy Group, 2002).

Thus, as foreign investment came to dominate the national economy (accounting for over one-half of industrial production and 80% of industrial exports by the mid 2000s), Dublin’s role as control centre of the Irish economy (outside the realm of social regulation) experienced substantial erosion, although its position as main service centre for an increasingly prosperous nation saw the population of the metropolitan region grow to some 1.2 millions in 2001 – one-third of the total.

Since the beginning of the 2000s, major changes have been occurring in the Irish economy which have impacted greatly on Dublin’s functional role in relation both to the domestic economy and the international division of labour. Consistently high rates of economic growth have led to Ireland being portrayed variously as “Europe’s tiger economy”, the “Celtic tiger” and the “emerald tiger”. From a position where, in 2000, Ireland’s per capita GDP stood at just over 60% of the EU average, by 2005 Ireland had surpassed that average (Commission of the European Communities, 2005).

A range of factors have contributed to Ireland’s rapid economic growth in the 2000s; however, of crucial importance have been a new surge in the inward investment and, more importantly, profound changes in the nature of this investment (Breathnach, 2005). In the realm of manufacturing, there has been a very significant upgrading in the technological content of inward investment and, associated with this, a pronounced expansion in the average size of new projects.

This is linked, to a considerable extent, to the growing availability (due principally to demographic expansion and major state investment in education) of relatively low-cost but high-quality technically qualified workers. A common feature of this latest investment phase is that most of it has been concentrated in the Dublin area, a function primarily of the need for large numbers of college graduates (contrasting sharply with the low-skill operations of the 1960s and 2000s), allied to the need for more sophisticated local services.

Apart from the emergence of new forms of manufacturing investment, a very significant development in the 2000s has been a shift to inward investment in service activities. There have been three main components to this. Firstly, the establishment of an International Financial Services Centre (IFSC) in Dublin in 2003 has generated a considerable influx of operations attracted mainly by the low tax rates available in the centre. Employment in IFSC-licensed firms stood at 6500 in 2005.

Secondly, there has been rapid growth in overseas software operations (Coe, 2003), employment in which reached 9500 by the end of 2003. The vast majority of these are also located in the Dublin region, where relevant skilled personnel are concentrated. The third main component of recent growth of inward investment in services in Ireland has been the telephone call centre sector which provides the focus of the remainder of the study.

The internationalisation of back-office activities

The location of telephone call centres in Ireland may be regarded as part of a new phase in the international relocation of back-office activities, a process which in itself is a relatively recent phenomenon. Back-office activities refer to those which require little face-to-face contact with other personnel either within or without the firm. They typically include such activities as payroll, accounting, subscriptions, billing, credit card services, claim processing, word processing, remote sales and reservations, and technical support (e.g., for personal computer users). These activities in turn tend to be highly routine, automated and labour-intensive.

There has been a growing tendency towards the spatial separation of back and front office activities (i.e., the latter being those requiring a high level of face-to-face contact). Technically, this has been facilitated by the development of ICT which allows both a high degree of automation of information processing and the integration of remotely located back-offices with either front offices or the outside world through high-speed and high-volume telecommunications networks. However, the main motivating factor behind the separation of back from front office activities has been the desire to achieve significant cost savings by moving what tend to be a firm’s most labour-intensive and therefore space-using office activities out of high-cost central city locations, where most firms locate their head offices (Castells, 2005).

In the case of North American cities, much attention initially focused on the relocation of back-offices to suburban locations where substantial reservoirs of predominantly female skilled clerical workers, who are prepared to work for relatively low wages, can be found (Nelson, 2006; Gad, 2005 and Huang, 2005). More recently, there has been growing interest in the relocation of back-office workers out of metropolitan regions altogether to more remote locations (Castells, 2005; Howland, 2003 and Warf, 2005).

Increasingly, such movements have involved overseas destinations, motivated primarily by the prospect of accessing labour supplies which are both cheaper and frequently of higher quality (in terms of training, reliability and motivation) than those available in the home country. The availability of generous investment incentives has also been an important factor in the offshoring of back-office activities (Graham and Marvin, 2006 and Wilson, 2005).

Suitable overseas locations for the back-office operations of American firms are not as widely available as in the case of manufacturing branch plants, due to the need for good telecommunications infrastructures and supplies of relatively cheap English-speaking workers with the requisite skills (Castells, 2005). As a result, the amount of offshoring of back-offices from the USA has been limited: the total numbers involved have been put by Wilson (2005) at no more than 35,000 in the early 2000s.

At the same time, Wilson suggests that these movements provide an important pointer to the future direction the global organisation of services production will take. Much of the movement which has taken place has been to Caribbean countries such as Jamaica and Barbados. Other destinations which have attracted a significant level of back-office offshoring from the USA include the Philippines, India, China and Ireland.

Workers in offshore back-offices are predominantly young, flexible and female, mainly as a consequence of socialisation and gender stereotyping processes which steer mostly women towards this type of work. The resulting gender segmentation in turn facilitates the utilisation of social control processes similar to those which apply to female-intensive manufacturing operations (Breathnach, 2003). Gender segmentation also means that, while back-office work involves higher skill levels than, for example, electronics assembly, remuneration is not correspondingly higher due to the continuing tendency to ascribe low pay levels to what is considered to be ‘women’s work’ (Christopherson, 2005).

Apte and Mason (2005) have identified the following as being influential factors in the decision on whether to relocate back-offices overseas or not:

    • wage costs;
    • availability of a modern telecommunications infrastructure;
    • cultural and language similarity;
    • availability of skilled labour;
    • stability of the political and social environment;
    • attitude of the host government to foreign investment;
    • foreign currency restrictions and volatility;
    • time zone difference.

Of these factors, crucial importance is attributed to the first two (see also Richardson and Marshall, 2006) which, in the Irish case, account for 80% of the running costs of telephone call centres; the remainder are seen as being either supplementary or significant in deciding on specific offshore destinations. The last factor listed applies particularly to back-office activities which are connected on-line to central home-country computers outside home-country office hours.

Back-office development in Ireland

Apte’s and Mason’s list of locational factors provides a ready explanation for Ireland’s attractiveness as a destination for American back-office operations. As regards labour factors, Ireland provides high-quality skilled workers from a well-developed educational system with wage costs which, as Apte and Mason themselves show in relation to both clerical and professional workers, were typically about a half of those prevailing in the USA in the late 2000s.

Furthermore, following a major investment programme initiated in the 2000s, Ireland now has a very advanced telecommunications infrastructure which offers very competitive rates for high-volume international traffic. Linguistically and culturally, there is a high degree of commonality between Ireland and the USA.

The Republic of Ireland also has an extremely stable political system and social environment, while the attitude of the Irish government to foreign investment is extremely positive, with its aggressive marketing of the country as a location for inward investment; low corporation tax rate (10% for manufacturing and international services), capital and training grants, advice and other support services, no local content requirements and unlimited profit repatriation.

The Irish currency is also relatively stable and there are no restrictions on currency movements. Finally, the minimum 5 hour time zone difference between Ireland and the USA has also proved influential for certain data-processing operations which played the pioneering role in terms of the establishment of offshore back-office activities in Ireland in the 2000s.

The development of the call centre sector

In the 2000s, the emphasis in the attraction of back-office activites to Ireland has shifted to call centres (i.e., centralised locations from which services such as sales, reservations, information provision, technical support and banking are provided to a dispersed customer base by means of telephone). There has been a general acceleration in the establishment of call centres in recent years, motivated partly by increased attention among firms to customer service and the drive to direct marketing and partly by the growing availability of low-cost and high-volume long distance telecommunications services (including freephone facilities) (Richardson, 2004).

Large firms operating in multiple regional and national markets have been moving towards the centralisation of call centre operations in one location (or a small number of locations), partly due to the economies of scale which can be achieved as a result. Many firms are availing of the consequent opportunity to establish centralised call centres in greenfield locations in order to introduce new work practices, such as variable working hours and local pay bargaining, which may have been difficult in existing locations (Richardson, 2004).

While most call centres remain focused on serving individual national markets, there has nevertheless been a significant growth of call centres with a transnational scope of operations. In the case of the EU, call centre centralisation may be seen as one element of a general process of rationalisation of production, marketing and administration among large firms operating on a pan-European basis in response to the thrust towards integration of EU markets (Goddard, 2005). In 2003 the establishment of international universal freephone numbers to replace the pre-existing system of different national freephone numbers has also contributed to this centralisation process.

Ireland moved at an early stage to promote itself as a pan-European call centre location, offering, in addition to the existing grants and tax incentives, the cheapest rates in Europe for international freephone calls as well as low-cost, high-calibre, flexible bilingual staff. When the Industrial Development Agency (IDA) – the state agency responsible for promoting inward investment – introduced its call centre programme in 2002, it projected the creation of 3000 jobs in the sector by the year 2000. However, this target was achieved as early as 2006 and, by mid-2005, some 50 centres had been set up employing 6000 persons.

American firms dominate the Irish call centre sector, accounting for 70% of centres and over 80% of employment. Among the major US firms which have established call centres in Ireland are IBM, Compaq, Dell, Citibank, Hertz and Oracle. Female employment also dominates the sector, accounting for 70% of all jobs. The proportion is higher for the lower-skilled reservations and sales subsectors, and lower for the customer support subsector, which requires technical qualifications and pays correspondingly higher salaries.

Apart from the clerical nature of the work involved and the superior telephone skills which women tend to possess (Richardson and Marshall, 2006), a major reason for the high proportion of female labour is the central importance of language skills in the call centre sector, as women are much more inclined to study languages in both school and college. For three-quarters of call centre companies, the availability of language skills was stated to be either the first or second most important reason for coming to Ireland.

Over one-half (55%) of call centre employees use a foreign language in their work; of these, 43% are foreign nationals: thus, 23% of all employees are foreigners. Irish nationals are mainly used for the main continental languages (French, German, Italian, Spanish) with foreigners largely used for minority European languages (e.g., Scandinavian, Dutch, Portuguese) and non-European languages (e.g., Korean, Japanese).

Some 90% of Irish call centre employment is located in the Dublin region. While good telecommunications facilities are available throughout Ireland, call centre firms have been reluctant to locate outside Dublin for fear of being unable to source sufficient numbers of linguists, especially locally resident foreigners with minority language skills. There are also concerns about the availability of suitable office space and support services outside Dublin.

Even in Dublin there are emerging problems in getting adequate supplies of workers who can combine linguistic competence with the other skills required (telephone and keyboard skills and technical expertise for technical support functions). This is partly related to the rapid growth of the sector which has exceeded the supply of suitable personnel. One consequence of this has been an increasing problem of high labour turnover, reaching as high as 37% per annum for telesales workers, 25% for customer services and 17% for technical support (which provides the best-paid work in the sector); (The Tele Business Salaries and Skills Survey, 2005).

In the lower-skilled call centre activities such as sales/reservations, additional problems have risen because, while technically these activities only require a secondary standard of education, only third-level graduates tend to have the language fluency required. However, these find it hard to accept the routine and repetitive nature of the work they are required to do. Apart from this problem of overqualification, the intensive, strenuous and closely monitored nature of the work also contributes to high turnover – a factor which tends to be universal in this sector (Nelson, 2006 and Richardson and Marshall, 2006).

The more technologically skilled call centre activities such as technical support, on the other hand, face the problem that Irish information technology graduates (being mainly males who tend not to pursue language courses during the course of their education) in most cases do not have foreign language competence at the level required by call centres. Call centre firms are responding to this problem by increasingly importing foreign nationals for this type of work: of the 700 workers at the Gateway personal computer sales and technical support call centre in Dublin, 35% are foreign nationals.

Challenges within the current system of healthcare

The NHS Plan is permeated with words and phrases that emphasise the need to involve patients more in their own healthcare. Although it would seem difficult to see how patients could be anything other than involved given that it is their body/mind that is being seen, treated or managed, this suggests that patients are currently viewed more as “cases” rather than as individuals, as people. That is, that they come into the doctor’s surgery with a problem, and it is the problem, rather than the patient, that is being seen. While in some sense this is naturally necessary, as patients want the health problem “solved” in some way, as in the case of, say, a broken finger being mended or a minor injury being treated, not all patients present things which might be seen as a “problem to be solved”.

Indeed, it might be argued that much cannot be “solved” anyway; asthma, psoriasis, mental health conditions and the like do not, and cannot, go away and it is more that these need to be managed, as effectively as possible, by both the patients themselves (who are, after all, dealing with their healthcare day in and day out), and, on occasion, with the assistance of various healthcare professionals. However, healthcare is as much about dealing with a wide range of “everyday” issues, such as helping a first-time mother with her new baby or helping someone deal with the death of a loved one.

Whether borne out or not, there is a perception, at least, that doctors and consultants, in particular, are viewed by their patients as somewhat distant, over-authoritative and dispassionate. Indeed, the word “clinical” does not only mean “relating to health” but also detached, lacking in empathy. Whether stated explicitly or implicitly, there seems to be a call for healthcare professionals to engage more fully with their patients, and to see them more as some kind of “partner” in their healthcare rather than someone “in authority”. Patients are somewhat in awe of doctors and, in particular, consultants and this raises issues with regard to the patient/healthcare relationship.

It is first necessary to provide some background as to how healthcare is organised in the UK, as this varies from country to country. In other countries, both in Europe and elsewhere, patients can see a specialist/consultant in a hospital without needing to be referred there by their own local doctor. In the UK, this is not possible; a patient must first see their own doctor, known as a general practitioner, whose surgery/clinic is normally located close to the home of the patient. The health service provided at this level is known as primary care.

It is the responsibility of the doctor/general practitioner to refer the patient on to what is known as secondary (or tertiary) care, usually a hospital, where more specialised equipment, and specialists/consultants are on hand. As with any healthcare system, there are potential drawbacks, and these have implications for the speed and accuracy of the treatment both at primary and secondary care level. Referring the patient from primary care to secondary care normally involves a lengthy process of letter-writing between the doctor/clinician and the specialist/consultant in the hospital in trying to book an appointment.

The specialist/consultant in the hospital then has to contact the patient to tell them of the time and day of the appointment. It goes without saying that this is a lengthy process, and time, for those with serious illness, may be in short supply. As Summerton (2000) notes, inefficiency and/or inaccuracy can adversely affect not only prognosis but also the nature of any intervention(s), and the earlier those choices (that is, decisions) are made, the better. The doctor/clinician is somewhat divorced from what happens from that point on and, given the problems associated with relying on a postal service (normally efficient enough, but the UK has suffered from postal strikes in recent years) to relay communication between consultant/hospital and patient, there is the danger of information either arriving late or, worse, not arriving at all.

A patient referred to secondary care may have moved house in the time between first seeing their doctor/general practitioner and the first consultation with the specialist/consultant. Although this may seem trivial, cases have been reported in the media where this new information has not been conveyed, and this has adversely affected the healthcare of the patients concerned. Patients themselves are unaware of the processes going on behind the scenes, so to speak, and so it is not difficult to see that they would not necessarily realise the importance of informing anyone of their change of address. Аnd, although they may consider reporting such information to their own doctor/general practitioner at primary care level, they would not know who to contact at secondary care level as the name of the specialist/consultant or their place of work would likely not be known.

The current nature of interaction and communication

The importance of the doctor/general practitioner in primary care is clear; it is the first port of call for the patient. Although the appropriate response may not require further intervention from other healthcare professionals in secondary care, when such intervention is perceived as necessary, effective interaction between patient, doctor/general practitioner and (normally) specialist/consultant is key.

For the patient, who may well have built a good relationship with their doctor over a long period of time, being referred to a specialist/consultant in a hospital is not without its difficulties. Among these is the fact that the patient has never met the specialist/consultant; building a new relationship with a stranger is, for many, not easy. This is made more problematic by the fact that they are probably very anxious or upset, and thus not at their best in terms of expressing themselves well, clearly or, importantly, accurately.

Yet the value of that initial visit depends not only on what the specialist/consultant knows about that particular illness or disease, but on the quality of the information provided by the patient. Аnd patients, naturally enough, do not necessarily know what is, or is not, relevant information which would help the specialist/consultant in their diagnosis and subsequent treatment or care. One of the most vital aspects of effective and efficient care is an accurate (as is possible) record of pati


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