Consultants are not to blame for our accident and emergency problems, but we do need radical changes in work practices, writes Brendan Drumm
Yesterday I visited the Ballymun Primary Health Care Centre, which opened for business on Monday.
This health centre demonstrates how developments in primary and community care can radically change the way health services are delivered. They reduce the need for people to travel to hospital by providing services such as physiotherapy, X-ray, etc, and make it easier for people to return home from hospital with organised continuing care delivered locally.
We need more initiatives like this if we are to deliver sustainable solutions to the difficulties facing patients in some of our hospitals' accident and emergency departments. But we also need to make major changes to the practices and processes that operate in these hospitals.
Recently I pointed out that consultants have an important role to play in this modernisation process. Unfortunately the Irish Hospitals Consultants' Association accused me of scapegoating consultants for the problems within emergency departments. This response has been unhelpful to the current debate and serves no purpose except to create demoralisation and resentment among consultants.
At no time did I blame consultants for the problems of our health service. In fact, when I spoke last week at the Oireachtas Joint Committee on Health and Children, I pointed out that it was unfair to blame consultants for such problems. What I said couldn't be clearer - "The majority of consultants provide the cornerstone of the health service, just as GPs do in the community. The experience is that their commitment to the health service is underestimated by the community. However, we need more of them. It is not fair to blame the ills of the health service on consultants."
What I did criticise, and what needs to radically change, are some of the outdated work practices which exist within our hospital systems, practices which do not serve our patients or staff and sometimes manifest themselves in people waiting an unacceptable length of time for diagnostics, out-patient appointments and both elective and emergency admissions.
This is why we really have to ask ourselves why some hospitals are experiencing problems in their emergency departments and others are not. Let's look, for example, at the process that occurs in some emergency departments. When somebody arrives with a GP's referral letter they can have up to five contacts with medical personnel before coming to the end of the process. A patient can see an experienced senior nurse, who then refers him or her on to a junior doctor and possibly a registrar within the emergency department. If the patient is attending during normal working hours, he or she may be seen by a consultant. If there is a decision to admit, a junior doctor will be brought down from a ward in the main hospital to again assess the patient and this is despite the fact that the decision to admit has already been made by an experienced consultant. This junior doctor will then consult with his or her registrar to reassess the patient prior to admission.
Consultants highlight that they are on call and frequently attend for emergencies. This commitment is appreciated but not sufficient to meet the needs of today's patients. For example, the majority of attendances at emergency departments are between 5pm and 1am. We need emergency consultants and diagnostic personnel working during those hours when their expert decision-making skills are most needed. We obviously have to be willing to pay for such a service from skilled professionals.
I appreciate that emergency department staff can experience frustration with hospital systems that need to become more efficient. For example, when admitted, patients often have to remain in hospital awaiting diagnostic tests, which sometimes cannot be provided for a number of days because of excess workloads for X-ray and other departments. We need to extend the length of time that these types of services are available and as a result reduce the length of time people need to spend in hospitals.
If we continue to put up with unwieldy and outdated practices in the health system (where patients and staff must navigate through cumbersome hospital processes) and do not address the gaps in our community and primary care, it is certain that we will need more acute beds.
If we change our present practices and follow those of advanced health systems around the world, it is likely that we will have sufficient acute beds for our present population but will naturally have to plan to accommodate our growing and, more importantly, ageing population.
At present we have a shortage of publicly-owned community long-stay beds. In addition, the spread of acute beds around the country may not be ideally balanced. The HSE is studying its overall bed requirement, particularly in light of the growing numbers of acute beds being developed by the private sector, and if a response is required it will be based on patient need and evidence - not inefficient processes.
The following analogy will illustrate my point. If you have a train service and the track is old and rusty, trains will be slow and travel times will be delayed. The way to improve the service for passengers is not to add more carriages to the end of a slow train. What passengers need is for the rails to be repaired to get the train moving quicker.
Prof Brendan Drumm is chief executive of the Health Service Executive