Inequities must be addressed at Tallaght, which is providing quality care against all the odds
TALLAGHT HOSPITAL is rarely out of the news: worrying issues have arisen in relation to radiology services, GP referral letters, care in accident and emergency, and the outsourcing of patient correspondence.
Superficially it may appear that such concerns are due to poor management and governance. However, closer analysis demonstrates clearly that these serious problems are symptoms of a more serious disease: the dysfunctional system used to allocate human and financial resources to meet healthcare needs. The hospital in Tallaght, and health provision in the region the hospital serves, has suffered grossly because of this system – a system the Health Service Executive has failed to address – with the result that resources have never matched needs, nor are they provided on an equitable and comparable basis in relation to other providers or areas.
The following facts bear out this analysis. Since it opened in 1998, Tallaght hospital has, at least for its core activities, become the busiest hospital in the State. In 2010, and for the first quarter of 2011, HSE figures show there were 93,016 attendances in its AE unit. The next busiest AE was Beaumont, with 59,148 attendances, followed by the Mater, with 58,742, St James’s Hospital with 56,174 and St Vincent’s hospital with 51,923.
On inpatient discharges, Tallaght again heads the list with 30,981 discharges compared with, say, St Vincent’s at 18,624. The other hospitals vary between these numbers.
Tallaght also tops the list on outpatient attendances, with 249,395 compared to St Vincent’s at 134,249 and the other hospitals again between these figures.
Roughly speaking, Tallaght has been doing over 30 per cent more patient care than the other Dublin hospitals. The role of the HSE is to ensure that comparable human and financial resources are provided, based on patient activity. Sadly, the reverse is happening, with the least resources going to where need is greatest.
A shortfall on the requisite number of consultants was the fundamental issue identified in the Tallaght Hospital Review , conducted by Dr Maurice Hayes in September 2010, when he inquired into the issue of radiology reporting. He reported that, relative to other Irish hospitals, “the degree of understaffing in Tallaght Hospital in 2009 was substantially greater than in the other sampled hospitals”.
For example, in adult radiology, Tallaght had 5.5 consultant radiologists, while another Dublin hospital had 10 – yet Tallaght was doing 75 per cent more work in this area than that hospital. Hayes recommended as a matter of urgency the filling of two posts in Tallaght “to avoid the same problem occurring, ie the creation of another backlog”.
It is not just in radiology that the HSE has poorly served patients at Tallaght. The numbers of approved permanent consultant posts in the other Dublin teaching hospitals are: St James’s, 154; Beaumont, 139; St Vincent’s, 117; the Mater, 114; and, lastly, Tallaght, 100.
It is now accepted that a properly functioning acute hospital depends on appropriate health service provision in primary care and in continuing non-acute care beds. The Tallaght region is seriously under-provided in both, leading to extreme pressure on the hospital.
To illustrate the comparative shortage of GPs, one might compare Galway city and the Tallaght urban areas: both have similar populations (more than 70,000), yet Galway city has more than 40 GPs, compared to 26 GPs for Tallaght.
Further, the absence of an out-of-hours GP on-call system means people have nowhere to turn except the hospital’s AE. Fettercairn, for example, with more than 7,000 people, has no GP service. The provision of so-called “step-down” beds for patients who have completed their acute care treatment is very poor in the Tallaght region compared with other catchment areas. This compounds the problem of “blocked beds”, adding to long waits for AE admissions and elective procedures. This amounts to 50 of the 640 beds at any one time.
Tallaght hospital is funded by the HSE to service a population area of 350,000. This is stated HSE policy. In reality, the HSE has required the hospital to service 500,000 people. The hospital has pursued this issue at the highest levels within the HSE, which is responsible for ensuring that GP referrals are appropriate in each of the defined population areas. In particular, the N4 corridor and Clondalkin area is supposed to be serviced by St James’s rather than by Tallaght.
This has significant financial implications for Tallaght hospital. It also means an unsatisfactory service for patients: for example, Tallaght has only 1.8 dermatologists for paediatric and adult patients combined, while there are five dermatologists in St James’s for adult patients alone.
The staff and board of Tallaght hospital welcome the opportunity to serve as many patients as possible – once appropriate resources are provided.
However, taking into account their HSE-assigned catchment area populations, a breakdown of Dublin hospitals’ annual financial allocations yields startling figures. Tallaght’s allocation is €176 million, compared with St James’s €220 million and €200 million at St Vincent’s. This equates to €800 per person in St James’s, €727 in St Vincent’s – and €350 for Tallaght.
Those responsible for allocating human and financial resources will have to urgently address these gross inequities against the background of the recently announced Health, Information and Quality Authority (Hiqa) inquiry into patient care in Tallaght’s AE. As the medical board of the hospital has said, it is not possible to deliver optimum, safe care with continually diminishing resources and steadily increasing patient activity.
The hospital has, in fact, a strong track record of providing quality care in the face of almost insuperable demands with inadequate resources. It has constantly advised its funder, the HSE, of the staffing and other resources required to rectify obvious imbalances. No wonder the Hayes report found the relationship between the hospital and the HSE “seemed to be more fraught than most” when it expressed concern at “the length of time taken over the years by the HSE and its predecessors in responding to the need for additional radiologist consultant posts to meet a steadily rising workload”.
A dysfunctional allocation system such as that operated by the HSE means resources follow critical patient incidents that receive media attention: it took the Hayes report to highlight the need for more radiologists, and it will take the Hiqa inquiry to highlight the need for adequate resources to enable Tallaght’s AE unit to function properly.
Good management and governance are crucial in ensuring patient care. Steps have been taken to address deficits. The hospital has an outstanding new chief executive in Eilish Hardiman.
There is now in place a new, smaller board with the full range of corporate, legal, medical and other expertise recommended in the definitive Madden report on patient safety. Indeed, the hospital has had in place since March 2010 a small expert transitional board of management with strong external expertise. This did not prevent concerns arising over patient care because no manager or board will succeed unless the underlying causes of entirely foreseeable problems are addressed.
The Minister, James Reilly, has appointed a “special delivery unit” to address the real issues of hospital performance and to ensure “money follows the patient”. Tallaght hospital surely merits its urgent attention.
Triona Murphy is chairwoman of the Tallaght Hospital Action Group; Dr Fergus O’Ferrall is Adelaide Lecturer in Health Policy at Trinity College, Dublin, a former member of the board of Tallaght hospital and a member of the board of The Irish Times Trust; and Prof Ian Graham is a cardiologist, chairman of the European Cardiovascular Prevention Committee and former vice-chairman of the board of Tallaght hospital