There are times when I feel sorry for the HSE’s management and staff. Last week was one of those times. The organisation was urged to apologise for issuing a memo to acute hospital managers on the legality of removing “trespassing” patients from beds using “minimum force”. These are patients whose acute health problems have been solved but who cannot vacate their hospital beds because their home situation is unsuitable for their needs. The vast majority of these patients are older people.
While the label “trespassers” is even worse than “bed-blockers”, and a sign that ageism is alive and well within the health system, it is easy to see how this advice could seem reasonable to lawyers and hospital management who have an impossible job to do. There is a huge problem which is not going to be solved by more beds and resources. An extra 500 beds could be provided tomorrow and they would be filled with patients within 24 hours. The problem is that too many people want to avail of acute hospital services even when the acute setting is unsuitable for their health needs. They believe that if they can just get themselves and their relatives into hospital all will be okay. This is a mind-set problem for which politicians and unrealistic expectations of citizens are to blame.
The Department of Health, health experts and health service managers have known for more than 50 years that acute hospitals are over-utilised. In 1966, a White Paper – The Health Services and their Further Development – led to the development of the regional Health Boards. This was unequivocal in relation to hospital beds: “It must be a prime object of policy to ensure that there is no avoidable use or unnecessarily prolonged occupancy of acute hospital beds.” Furthermore, health services must “facilitate the care and treatment of patients in their homes”.
Admissions to acute hospitals tripled between 1951 and 1964 because of “a growing preference for some years for confinement in hospitals”. People no longer wanted to be treated in their homes by GPs or District Nurses. Fifty years later, the same problems persist because patients’ expectations are not being managed. In fact, a greater proportion of the population is now using acute services than in 1966. Fifty years ago, about 10 per cent of the population were admitted to hospitals each year. According to the Healthy Ireland Survey 2016, 11 per cent of those aged 15 and over were admitted to hospitals in the past 12 months. A further 12 per cent visited an Emergency Department and 14 per cent were admitted as a day patient in the past year. More than a quarter saw a hospital consultant. The planned shift to community and home care is clearly not working.
This is not just an Irish problem. All over the world older people end up in acute hospitals when medicine cannot help. A recent global review carried out by experts in the University of New South Wales, Australia, involving 38 major studies, found that more than one-third of patients nearing the end of life received non-beneficial treatments in acute hospitals. Up to 77 per cent received non-beneficial antibiotics, cardiovascular, digestive and endocrine treatments, dialysis, radiotherapy, unnecessary tests, and useless chemotherapy. Non-beneficial tests were performed on almost half of patients with do-not-resuscitate orders.
Half of older people died in intensive care units when they would have been better off at home. Most of the non-beneficial treatments were performed because relatives insisted on them. The authors concluded “that the use of non-beneficial treatments in acute hospitals is widespread”.
The HSE does huge work and does not often get the credit it deserves. Acute hospitals see a staggering number of people every year. In 2014, the latest year for which statistics are available, acute hospitals treated 1,592,672 patients. It is time to have a conversation about what acute hospitals are for, which is for people with acute health problems. This conversation needs to be started by the HSE.
Politicians must start praising primary-care services and stop trying to keep hospitals open when they are no longer fit for purpose. The HSE press office and spokespeople need to be more assertive with the media. Doctors need to have honest conversations with relatives. If an older person cannot be helped, this needs to be stated up front. Things are improving, believe it or not. In 1966, the average length of stay was 18 days. Now it is one-third of that.