DONALD G. WEIR,
Sir, - Your Editorial of March 14th on the strike by nurses in hospital emergency departments rightly highlighted the shortage of hospital beds as the dominant cause of the problems facing our emergency services.
As a senior physician, I can verify that during the 1960s and 1970s we had enough beds in Dublin to cope with the requirements of emergency departments. During the 1980s, for economic reasons, there was a marked reduction in the number of acute medical beds available. This has persisted through to the 1990s and 2000s at a time when there has been a significant increase in the population.
Mr McCreevy, the Minister for Finance, has written to the Irish Medical Times (March 18th) pointing out that Government expenditure on the health services has risen from €3.1 billlion euro in 1996 to €8.2 billion in 2002 - a level which he believes is now above the average for other EU countries. He says that such a rate of increase is unsustainable. However, this has been a catch-up period for a grossly underfunded service.
His solution is that "service providers" have to put greater emphasis on efficiency so that the community can secure best value for the resources deployed. By far the most expensive aspect of our health system is our acute medical hospital service.
For those of us who treat patients admitted from emergency departments the most obvious inefficiency is that about half of these patients occupying acute medical beds at any one time are "medically fit", but cannot be discharged because they are socially dependent. It is not unusual to have patients who have been cured of their medical problems within eights days sitting in acute medical beds for over 100 days, waiting for transfer to other accommodation and thus using a bed to which a further 10 or more acutely sick patients could have been admitted and treated.
In my view, the single most important reason for our failure to admit medically sick patients from emergency is our inability to discharge "medically cured", socially dependent patients. This puts enormous pressure on the remaining beds. In addition, some patients who are discharged back to the community have to be readmitted to hospital within days, because of the lack of primary care.
The fact that we are living longer means we have more elderly people tending to require more frequent admission to hospital. However, two aspects of this problem have become much more prevalent in recent times.
The first is the tendency of families to leave elderly dependent relatives, once admitted, in hospital and refuse to take them back home again when medically cured. This is a much more common problem today than 30 years ago. Whatever may be said about the decline in what many of us would feel are the obligations of families in society, if Mr McCreevy were to offer better inducements, both financial and social, to patients' families, this problem might well be significantly eased.
The second aspect is the fact, often repeated, that more than half of the patients coming to our emergency departments are there as a result of disease or injury caused by the abuse of alcohol and tobacco. Even if such abuse were to stop tomorrow, it would take many years for the full effects to be reflected in emergency department admissions. However, adequate educational and control mechanisms have to be applied now for benefits to be seen in the future. Once again, only Mr McCreevy and his colleagues in government can put in place the necessary legislation to reduce such abuses and the resultant cost to the community.
And no matter how efficient the "service providers" are, without a substantial increase in the number of hospital and community beds, the situation will remain untenable. - Yours, etc.
DONALD G. WEIR,
Retired Professor
of Clinical Medicine,
Trinity College and
St James's Hospital,
Dublin 8.