There is a certain inevitability about headlines focusing on the periodic spike in the number of people on trolleys in hospital emergency departments. But emergency department chaos is just the tip of the public health service iceberg; under the surface is an entire hospital ecosystem that is increasingly out of control.
While it is true that pathways for patients with cancer have improved and are to a large extent ringfenced from funding pressures, most people waiting for a hospital appointment or a bed do not have cancer.
Many have gallbladder problems or hernias that need surgery, and there is a steady stream of people in considerable pain with severe arthritis, who need replacements hips and knees.
Meet the new “poor” of Irish healthcare, on what can seem like the never-never of hospital waiting systems. Just because you have a diagnosis and a treatment plan does not mean that you are safe, however. Disease rarely remains static, so the routine often morphs unexpectedly into the urgent .
It is patients in this group who especially struggle to access appropriate care, as the story of Una* illustrates. In her 60s, and with a moderate degree of intellectual disability, Una lives in residential care. About two years ago she was diagnosed with gallstones and came under the care of a gastrointestinal surgeon in a Dublin teaching hospital.
Epilepsy
Una also has a lifelong history of difficult- to-control epilepsy, which is looked after by a consultant neurologist at the same hospital.
Gallstones cause inflammation of the gallbladder, leading to acute episodes of cholecystitis and, in time, chronic inflammation. In Una’s case, this meant several trips to the emergency department for acute symptoms and required one admission last year for treatment with antibiotics and for pain control.
In a properly functioning, well-resourced system, Una would have been listed for surgery at this point, and operated on within weeks. In fact, Una was told she was being placed on a “priority” waiting list for gallbladder surgery. Both her carers and hospital doctors had by now noted that the chronic infection was affecting her ability to walk. Her seizure activity had also increased.
Early this year, Una became acutely unwell , vomiting and experiencing severe abdominal pain. Her relatives brought her to a local private hospital, where she was admitted and, within one hour of arriving at the emergency department, placed on treatment for a severely inflamed gallbladder. A surgical assessment that evening was unequivocal: she needed an urgent operation to remove her gallbladder.
Una was by now quite confused, suffering ongoing absence seizures due to uncontrolled epilepsy. Her liver was under pressure because of the chronic infection in her gallbladder. It was now compromised to the extent that it could no longer metabolise her cocktail of anti-epilepsy drugs.
Because of Una’s complex neurological issues, she could not be operated on in the private hospital, which did not have the necessary anaesthetic or neurological expertise. So the surgeon contacted his colleague at the Dublin teaching hospital on the Monday morning.
But the senior surgeon in the teaching hospital could not arrange Una’s direct transfer. There had been no elective admissions to the hospital for weeks due to sustained pressure on its emergency department. Over the subsequent days, despite the efforts of both the surgeon and the neurologist, a bed could not be found for Una. Pressure from relatives also came to naught.
A full week after her initial hospital admission, all the Dublin teaching hospital could offer was for Una to be brought to its emergency department in the hope that she would make her way through the emergency department logjam in time for an operating-theatre slot the following Monday.
This worked: Una had her gallbladder removed, and has since made a good recovery.
Vulnerable
But for two years this vulnerable woman had endured a steadily declining quality of life due to a worsening medical condition. The public hospital system was unable to accommodate her clear medical needs, despite emergency department attendances and an emergency hospital admission flagging her deteriorating illness.
She ended up seriously ill, with her life at risk. And even when she was in need of urgent surgery in a safe environment, the only way this could be achieved was by joining the back of the queue at the Dublin hospital’s emergency department.
A safe health system would have sufficient flexibility that a senior surgeon could intervene to ensure proper care was available for a patient with this emergency condition.
Una is not an atypical patient: she has much in common with others on waiting lists for hernia repair, gallbladder removal or prostate surgery. But the system is not adaptable enough to cater for the not unusual complications or deterioration associated with these conditions, as when hernias become strangulated or an enlarged prostate completely blocks the bladder, causing acute urinary retention.
The system is unsafe for these patients, a fact acknowledged late last year by Health Service Executive director general Tony O’Brien. “It has not been possible to provide funding to address the substantial majority of the demographic and critical service cost pressures, some of which carry risks from a clinical perspective,” he warned.
The reality of our health service since the formation of the HSE is that of a reactive system adorned with short-term, sticking-plaster “solutions”. Funnelling patients already in the elective system through emergency departments puts intolerable pressure on a creaking service.
Waiting-list figures show that, in the 12 months to the end of January 2015, there was a 35 per cent increase (47,112 to 63,740) in the number of patients awaiting essential inpatient and day-case treatments. The number of patients awaiting outpatient appointments increased by 28 per cent, from 309,496 to 395,720.
How many Unas lie behind these figures? And will the measures announced by the Minister for Health on Thursday to tackle the emergency department crisis be enough to ensure that these patients don’t dangerously fall through the cracks in our public health system?
*Una’s name has been changed. If you would like to share your patient story, anonymously or on the record, contact Dr Muiris Houston at mhouston@irishtimes.com
