The beds crisis in our hospitals is not just about money. New ways ofmanaging admissions and discharges are crucial, writes Dr Tom O'Dowd
The Irish Patients' Association recent survey has shown a sharp fall in non-emergency admissions to Dublin hospitals. In reality this means that the main way of getting a bed in a Dublin hospital is to become seriously ill, go to Accident and Emergency, and after a number of hours, if you are lucky, you will find yourself in a hospital bed.
This means that patients who have gone to out-patients and had an orderly arrangement made to have their hernia repair, hysterectomy or hip replacement performed will find their operation cancelled at short notice because emergencies have taken priority.
There are now two kinds of hospital: public hospitals offering a free bed to the entire population but overcrowded and practising emergency medicine; and private hospitals, available to 40 per cent of the population, with good bed availability and no emergency admissions.
People are surprised to learn that in some A&E departments the number of surgical cases may be as low as 10 per cent, with most patients falling into a medical category such as chest pain, acute asthma, headache, diarrhoea and vomiting, and upper respiratory tract infections. Six out of 10 people attending an A&E department have non-urgent problems.
There is a year-on-year increase in people presenting to A&E and also in the number of emergency admissions. A&E now drives up to 80 per cent of in-patient activity in many of our hospitals which adversely affects quality of care and efficiency. Health economists say that hospitals with bed occupancies of 90 per cent or more can expect regular bed crises.
Emergency medicine has many players. Along with the hospitals it includes social services, ambulances, the voluntary sector, pharmacists, mental health carers, palliative care, dentists, general practitioners, neighbours, family and the media. (Most of these players are underused and not trained, but may be right there when the emergency occurs.)
More than any other area, emergency medicine requires specialist doctors and nurses who can make good-quality decisions about which case is urgent and about who needs further in-patient treatment.
Currently many of these decisions are left to junior doctors operating in a hostile medico-legal environment. Who can blame them for watching their backs in the bedlam of an A&E department?
In many Irish hospitals everything goes through A&E, including GP admissions. In Kilkenny, consultant physician Dr Garry Courtney and Dr Richard Brennan of the Irish College of General Practitioners have developed a medical assessment and pre-discharge unit for patients, and consultants also do a weekly out-patient clinic for GP emergency referrals.
Based on common-sense principles, it attempts to avoid importing delays into the system and to avoid having GP admissions and common procedures dealt with at A&E.
The Capita report to the employers and unions in January this year said "pro-active changes in consultant practices to encourage prompt discharge of patients" would directly improve the quality of care to patients.
Sir George Albertie, the new "trolley tzar" in the UK's National Health Service, takes this so seriously that he is insisting on a consultant rota to review hospital discharges by 9 a.m. daily. The NHS is encouraging the development of a discharge lounge where patients are clinically reviewed before discharge, their prescriptions and letter for their GP are provided, and a review date arranged.
This is a crucial part of the process because the Irish Patients' Association survey showed that nearly 10 per cent of return attendances to A&E were from patients recently discharged from hospital.
A&E departments have grown up around hospitals and have ended up providing a mish-mash of primary, secondary and emergency healthcare. In the NHS, experiments have been conducted with nurse-led emergency care centres and rapid-response teams who visit patients who have suffered recurrent falls and chest pain, in order to pre-empt unnecessary hospital admissions.
Our ambulance services are significantly underused in our healthcare system and their significant skills are not integrated into the system.
There is a sub-text among some hospital personnel that "if only the GPs would pull their weight we would not be in this mess". A sullen relationship has developed between some of our public hospitals and some general practitioners. A 1 per cent increase in the number of GP referrals to the hospital sector would close it down. The evidence shows that out-of-hours GP co-operatives have made surprisingly little difference to the emergency medicine demand in hospital. However, GPs with a special interest in emergency medicine have been shown to significantly reduce the numbers of admissions from A&E departments.
In the UK, NHS Direct is a 24-hour, nurse-led emergency helpline which is proving popular with the public. Seventy per cent of its calls are for advice on coughs, colds, minor injuries and diarrhoea and vomiting. While it has made little impact on the need for emergency hospital medicine, it has led to some reduction in out-of-hours work for general practitioners.
The NHS has established 40 walk-in centres in 30 cities across the UK which are nurse-led with software support. Those attending tend to be young, white, well-off and educated. Their problems tend to be minor injuries and illnesses, a need for emergency contraception and nursing procedures. The only impact evident to date is a levelling out in demand for general practice.
Many reports on emergency medicine point to the need for better bed management within our hospitals which includes shorter hospital stays.
There is pressure in the hospital system for more beds. It is unclear how many extra beds are being asked for or are needed. The Capita report states that one significant issue is the lack of sufficient rehabilitation, step-down, nursing-home and long-term care beds for patients who remain in acute-sector beds with nowhere else to go.
It is likely that if more acute beds are provided, they will be filled with emergency admissions at one end and blocked by people with nowhere else to go at the other.
For long-term benefit we need strategies that reduce the rate of growth in demand for emergency admissions. This means providing alternatives to admissions in the acute sector.
Emergency medicine is driving our service into the ground - but it needs to drive our thinking away from simplistic and traditional solutions. This means educating and challenging our communities about their use of our medical services. Our politicians have failed to do this and they have an insatiable demand for services in their patch at the expense of the national picture.
Minister Martin has injected new thinking into the healthcare system and has demonstrated the need for a strategic approach to healthcare.
However, since the Ballymascanlon fiasco, he has been given plenty of money but little political support.
The Health Strategy has never been strong enough to resist the doubt and self-interest of the backbencher who sidles up to the Minister for Finance.
Mr Martin's strategies have interested the innovators in our healthcare system. However, his Cabinet colleagues who can wax eloquently on the economy have let down the Minister, healthcare providers and patients by simply not understanding the issues involved in health.
Dr Tom O'Dowd is professor of general practice in Trinity College, Dublin, and a GP