Changes in work practices, 3,000 new inpatient beds and strong political leadership in the debate about health funding could help relieve the congestion at accident and emergency departments, writes Dr Garry Courtney.
Accident and Emergency Departments (AEDs) have traditionally been given a low priority in the grand scheme of hospital development, as shown by the relatively small number of consultants appointed to run these departments and the often undesirable locations they occupied.
They struggled on, made do and coped somehow with an increasing workload, deteriorating conditions and demoralised staff. Despite spasmodic crises from time to time, when some generally well-intentioned but short term "fixes" were put in, nothing much happened and as their terminal decline approached it was inevitable that "shock therapy" would be applied, in this instance by the public and media, and previously by the nurses' strike and work-to-rule.
This has forced the issue to the top of the crowded health agenda. Genuine attempts must now be made to solve the problem in a way that will deliver a self-sustaining, efficient and humane system, acceptable to patients, staff and the public.
Consultants in the larger hospitals have generally avoided AEDs except when they were "on-call" because the increasing number of admissions from this source has almost eliminated elective admissions in the medical specialities and has severely curtailed elective surgery.
Patients admitted through AED are often elderly and have a number of inter-related, complex medical problems that are difficult to manage either in or out of hospital. This leads to prolonged admissions, increasing the average length of stay which, in turn, reflects badly on the hospitals' waiting lists and other performance indicators.
Safe discharge of these patients requires greatly enhanced community supports which have not yet been put in place, such as more home-help, better carers' allowances, geriatric day care facilities and rehabilitation and step-down beds. It would not be unusual for large acute hospitals to have patients stay for over three months, and not infrequently for a year or more, because of inadequate community facilities preventing discharge.
The response from management has been poor due to inadequate central funding, a lack of clear prioritisation and the rapid turnover of senior managers who spend insufficient time in a post to formulate any new thinking in relation to solutions.
The Department of Finance will point to the rapid growth in expenditure in the health sector. However, this same Department, albeit under different leadership, presided over the swingeing health cutbacks in the 1980s which made the current crisis inevitable. Even the additional funding is illusory - 70 per cent of it has gone on salary increases necessary to prevent healthcare professionals in all sectors leaving in droves and the balance is being spent on long overdue capital developments.
Even the much hailed landmark of reaching the EU average health spend in 2001 bears closer scrutiny - for a start Ireland's figures include social-care spending which are not included in most EU countries health budgets so we are not comparing like with like. Thus Ireland's health spend is still below the EU average and this is despite a greater than 100 per cent rise in five years.
If Ireland has been spending below the EU average on health for decades, it will require a similar length of above average spending to bring us into line with our EU neighbours. It is even more unnerving to examine the spending record of the EU nation acknowledged to have the best health service - France.
Every French man, woman and child has €500 additional spending provided over and above Irish per capita spend on health. Our comparative spending deficit is around €2 billion every year and could not be reversed without very significant tax increases of around €1,000 per year for every Irish taxpayer. The French health system is better but at a cost and there is no evidence that Irish taxpayers will willingly fund such a service, even from a low tax base.
The role of the public in the AED crisis must be examined. It is generally acknowledged that a large proportion and possibly the majority of those attending AEDs could be better seen elsewhere, most probably in their GPs' surgeries. Another major issue in the AED crisis is the contribution of hazardous drinking to the AED workload. Excess drinking leads to serious illnesses, road traffic accidents and public disorder which often spills over into the AED itself.
It is into this turmoil of human misfortune and chaos that individual members of the public who are gravely ill or who are accompanying such a relative are thrown, and who feel desperately apprehensive and intimidated at the very time when they need calmness and coherence. Not unexpectedly they react with anger and accusation which elicits, in the current litigious atmosphere, a defensive posture from the staff and the institutions.
What changes are needed to bring the current chaos to an end? The timing is certainly right with the new Minister for Health, Ms Harney, bringing fresh energy to the portfolio. Of great significance are the planned 3,000 additional hospital inpatient beds. It is crucial that the mix of these beds recognises the need to much more rapidly assimilate AED admissions into the hospital ward beds so that ill patients receive treatment in calm surroundings from the most appropriate staff.
As most admissions from AEDs are of a medical rather than a surgical nature, it is essential that physicians are closely involved at an early stage in the care of these patients. If some of the 3,000 new beds were dedicated to the rapid assessment and treatment of these medical patients in Medical Assessment Units (MAUs), then the AED staff would be relieved of the major factor causing congestion.
New ways of working, such as simple changes to the structure of ward rounds and enhanced communication with bed managers and discharge co-ordinators will speed up planned discharges. Pre-Discharge Units (PDUs) can collate and co-ordinate disparate groups of inpatients into a final common pathway for discharge so that frustrating delays are prevented. The best and most accurate source of referral must be general practitioners who know their own patients' problems intimately. The "walk-ins" or those who for whatever reason by-pass GP assessment and treatment will be triaged in the AED to appropriate care pathways or referred back to their GP.
Large hospitals in Dublin which provide a supra-regional or national service have invested heavily in technology, staff and skills, so it makes no sense that their specialised beds be occupied by patients who do not require their expert care. It is vital that these facilities are protected for appropriate use by patients drawn from all over the State. Parallel development of specialities in hospitals outside of Dublin will allow many patients who now travel to Dublin hospitals, often for quite routine procedures, to have this treatment locally, thus easing pressure on the capital's hospitals.
The changes will not work without significant numbers of additional staff at all levels from GPs to emergency nurses and from hospital consultants to discharge co-ordinators. Despite more flexible working arrangements, even greater numbers of consultants will be required because of the increasing amount of these senior doctors' time involved in teaching and training the junior doctors and in keeping abreast of new developments themselves. More time is also being spent in meeting relatives of patients and in discussions of increasingly complex ethical issues.
Finally, the thorny issue of who looks after elderly relatives and who pays for this must be debated. Society has changed radically and it must be decided whether it is more appropriate to apportion at least some of these costs as social-care rather than healthcare.
Leadership is required from our political representatives in discussions with the public about whether the necessary additional funding for better social and health care will be drawn from increased taxation.
• Dr Garry Courtney is consultant physician and gastroenterologist at St Luke's Hospital, Kilkenny