Medical Matters: The Minister for Health recently told the lobby group, Patients Together, that the A&E problem was complex.
The recent survey by Prof Ray Kinsella and colleagues in UCD shows that patients use A&E because it is cheap and easier than the GP. The Kinsella survey also showed that 12 per cent of people would pay more tax to improve things.
A&E is the only place that public and private hospital patients meet on an equal basis. You are triaged on the basis of medical need, not on whether you have private health insurance. A&E drives up to 80 per cent of hospital inpatient activity because it sees sick people who need to be admitted.
This, however, leaves only 20 per cent of hospital capacity for planned admissions. In effect, our entire public hospital sector has become a medical emergency system.
The private hospital sector has become the system for dealing with planned surgical and medical care for an increasing number of insured and private patients. When the private sector looks at the public sector, is it any wonder it avoids attaching A&E to its list of services?
The players in A&E range from neighbours, ambulances, GPs, dentists, pharmacists and hospitals. A&E is the litmus test for the system. If the system is not coping, A&E shows it up. Adding more hospital beds will ease things in the short term but if the throughput is blocked, we are back where we started.
There are initiatives that help, however. A minor injuries unit helps and need not be placed in a hospital setting. Dr Muiris Houston has reported on the success of the medical assessment unit in Kilkenny which has only six beds. It provides rapid access for GP admissions and has avoided importing delays into the system. However, what works in Kilkenny may not work in inner city hospitals in Dublin or Cork.
What of general practice? Large areas of the country are now covered by GP co-operatives where doctors are on call with variable back-up from ambulances, psychiatry and social services. The service has received good feedback from patients, and doctors support the system. Disappointingly, the presence of a co-op has not been shown to decrease the use of A&E. In fact, patients who are heavy users of GP services are often frequent attenders at A&E.
The NHS in Britain has set up NHS Direct which is a 24-hour nurse-led emergency help line where 70 per cent of calls are for minor injuries, coughs and colds. It is very popular and well used by the middle classes. It has resulted in some reduction in GP out of hours but has had little impact on A&E usage.
The NHS has also experimented with walk-in centres which are again nurse led with software support. They see minor injuries, emergency contraception and do nursing procedures. The young , white, well-off and educated love it. It has resulted in a levelling-off in GP demand.
The Minister for Health, Ms Harney, has indicated more experienced nurses will be called on to help. They will certainly find a lot to do but may ease the problems of general practice rather than those of the hospital A&E department.
Part of the problem for our A&E departments is that they are located in hospitals, often tertiary hospitals, and run by increasingly experienced triage nurses and nervous, inexperienced hospital doctors. A nervous inexperienced doctor in a fevered medico legal environment will kick to touch and admit the patient if in doubt.
We know from a study in St James's Hospital that placing GPs in A&E results in fewer admissions to hospital. It was probably the experience rather than the discipline of the doctors that was the important determinant.
Now for the really bad news. Prof Kinsella pointed out that we need more GPs and fast. The GP crisis is upon us.
Our Government has put its money into our hospitals and marginalised the GP service for years. Now it is seen as the potential saviour of our struggling hospital system. The GP workforce has older males at one end and is being feminised at the other. Neither are prepared to work long hours in unsupported clinical practice.
And just over one in 10 of the Irish public thinks we should increase taxes to pay for our struggling A&E services.
Until we come up with better ideas for funding and running emergency medicine, we will continue to have to put up with the scandalous public squalor of A&E.
Dr Tom O'Dowd is professor of general practice at Trinity College, Dublin, and a practising GP.