Emergency workers say the AE fee hike is 'completely inappropriate'
SOME 26 years ago this month, The Irish Timesreported that the Minister for Health was about to introduce a new £5 fee for using the casualty department and other out-patient services. This was front page news and gave rise to much consternation. Hospital managers were surprised at the size of the charges and unions objected to the fees.
Now another Minister for Health has made front page news by increasing that emergency department fee from €66 to €100 for non-medical card holders who attend without a letter from their GP.
The concept of charging to use emergency departments was introduced in 1982 to reduce the number of unnecessary visits. Last week, Minister for Health Mary Harney made the same argument, noting that it would "help encourage people to avail of medical care in a more appropriate care setting through, for example, their GP or in a primary care centre".
It would allow emergency departments to increasingly concentrate on the care of more serious conditions. But that's not how the emergency departments see it.
The Irish Association for Emergency Medicine has described the hike in fees as "ill-thought out, ill-conceived and completely inappropriate".
Fergal Hickey is an emergency medicine consultant at Sligo General Hospital and president of the association. He says he cannot think of a good thing to say about the fee increase. He believes the fee increase will not reduce the number of unnecessary visits to emergency departments and says international research supports this view.
It has sometimes been argued that 70 per cent of visits to emergency departments are unnecessary but Hickey says this figure had never been validated and there was no evidence to suggest that it was true.
He says it is "a nonsense" to believe that the majority of people would spend hours sitting in an emergency department without good cause. Overcrowding in emergency department and hospital-acquired infections are two reasons frequently cited by people who simply refuse to go to emergency departments.
Hickey believes unnecessary visits account for about 10 per cent of patient numbers and says that many of those will not pay the increased fee anyway because they are eligible for the medical card - or they just won't bother paying.
The refusal to pay emergency department charges is a recurring problem for many hospitals. Figures published last year showed that 34 hospitals were owed €8.29 million in AE fees at various stages during 2006.
And in the past three years, hospitals have failed to collect almost €400 million in a variety of patient charges.
Hickey also argues that the higher charge could have a serious impact on patient outcomes. He says that certain patient groups need swift medical intervention but people with conditions such as suspected heart attack, meningitis or pneumonia might waste valuable time waiting to see a GP before going to the emergency department.
"Anything which discourages people with genuine emergencies from going to an emergency department is fundamentally wrong," he says. "Even if it only happens to a small percentage of people, it's still wrong."
The major increase in the fee has considerably lessened the gap between the cost of attending a public hospital and one of the many private clinics that have opened in recent times. Patients visiting one of the five VHI SwiftCare clinics are charged an initial consultation payment of €105, or €55 if referred by their GP.
All patients presenting to the Hermitage Clinic's emergency department in Lucan, Co Dublin are charged €120. However, private clinics generally charge extra for further treatment or tests. Charges for blood tests, X-rays, stitches and plastering at the SwiftCare clinics range from €30 to €95.
Naturally enough, private clinics are reluctant to be seen to welcome the price rise. A SwiftCare clinic spokeswoman says that "there may be an increase in business because of the increased costs in attending a public AE department".
However, she points out that the clinics are not emergency departments and are not suitable for patients with serious medical conditions such as chest pain or loss of consciousness.
The top five conditions presenting at the SwiftCare clinics are soft tissue injuries, fractures, sprains or strains, respiratory problems and minor cuts.
Fine Gael's health spokesman, Dr James Reilly, says there are undoubtedly concerns at the direction in which the health system is going. Pushing people out of public hospitals and into private clinics is another step in that direction, he believes.
Asked if the fee increase was likely to result in more people attending private clinics, a spokesman for the Department of Health says "the increase is likely to direct people to a more appropriate care setting, ie their primary care centre or GP, which is likely to cost less than the AE".
The fee increase has also been criticised by groups representing patients.
Janette Byrne of Patients Together says the increase in charges will hurt the most vulnerable, who regularly end up in emergency departments during the winter months through no fault of their own. And while the Department of Health encourages people to visit their GP first, she says there is "a serious shortage"of GPs and some people cannot get an appointment with a doctor for a day or even two. "So you wake up very, very ill and what do you do? You say, do you have the €100 because you know you won't get to see a GP - or do you stay where you are?"
She expresses surprise at the fact that the services being offered to patients are worsening, yet the Government's response is to charge them more for that service.
And the Irish Cancer Society urges the Minister for Health to ensure that the rise in hospital charges does not affect cancer patients adversely. Kathleen O'Meara, the society's head of advocacy, says cancer patients already suffer a considerable financial hardship.
"Cancer patients should not have to worry about whether they can afford a visit to their GP, the cost of drugs they are taking or the cost of having to make an emergency visit to an AE department if they are in a lot of pain or if they get suddenly ill and do not have a letter from their GP," she says.
Reilly says he suspects it all boils down to bringing in more money to the Exchequer, a claim denied by Mary Harney. "This is not just about raising money. . . it's about discouraging people from going in the first instance to AE," she says.
