Problems throughout the health service come to a head in the overcrowded A&E units. So what's to be done, asks Eithne Donnellan, Health Correspondent
There used to be two MRI scanners at Dublin's Beaumont Hospital, a fixed one and a mobile one. However, it was deemed too expensive for the hospital to have both, so the mobile one was removed. Unsurprisingly the result has been longer waiting times for scans among both inpatients and outpatients. For inpatients the wait can now be a few days, for outpatients the wait has increased from about three to nine months.
Aidan Gleeson, consultant in emergency medicine at the hospital's A&E department, cites the loss of this scanner in order to throw light on just one of the myriad factors causing A&E overcrowding.
"Doctors will hold on to patients on the wards waiting for that one final test, because they know it will take months for them to get it if they send them home and they have to get it as an outpatient. That is a waste of a bed," he says. If these patients had their scans quickly, they could be discharged and their beds given over to A&E patients, who then wouldn't need to be on trolleys.
While this is just one example of the inefficient use of the beds already in the system, Gleeson stresses that the most fundamental reason for A&E overcrowding is a shortage of inpatient beds in the first place. More than 3,000 beds were closed in the 1980s and 1990s. Only a fraction have been replaced. So there are fewer beds and a bigger population making demands on them, including an increasingly elderly population more likely to require hospital care.
Other inefficiencies, according to Gleeson, are the occupation of hundreds of beds by patients fit for discharge; some to nursing homes, some to hospice care if it were available, and others to rehabilitation if it were available.
And then there's the National Treatment Purchase Fund (NTPF), set up to buy private care for public patients waiting over certain periods for treatment. "What I think is completely obscene is public hospitals have set aside beds for NTPF work. So you can have varicose veins, you are on a waiting list for six months and one day, you ring up NTPF and they'll roll out the carpet for you to go into a public hospital and have your job done, essentially as a private patient, but at the same time you've got an 85-year-old lady with pneumonia from Coolock who has worked hard all her life, who has paid her taxes, and she's left on a trolley in the middle of an overcrowded emergency department for three days. And that is an obscene situation. If they want to do the NTPF work, in my own view it should be done exclusively in the private hospitals," Gleeson says.
While some suggest consultants' working hours are part of the problem, he points out that even if he worked around the clock there would still be patients on trolleys because there are no beds on the wards to move them into. And while some claim fewer patients would be kept in hospital after having been seen in A&E if they were assessed by consultants rather than by junior doctors, he says this is simply untrue. He looked at 100 consecutive admissions through A&E by junior doctors and there were at most only two patients he might have sent home. A&E overcrowding, he stresses, is not an A&E department problem but a hospital one. "The solution does not lie in the emergency department," he says, but in freeing bottlenecks elsewhere.
Gleeson, who is secretary of the Irish Association for Emergency Medicine, has a number of suggestions for the Minister for Health and Children, Mary Harney, to alleviate the current difficulties. But he warns they are not cost-neutral. He points to how the UK dealt with A&E overcrowding. A range of new initiatives were put in place and targets were set for the maximum length a patient should have to spend in A&E. At present the target is four hours and the majority of UK hospitals meet it.
Instead of having patients coming into hospital two days before an operation to have blood and other tests done, the UK set up pre-operative clinics which these patients attend as outpatients and then they arrive in hospital on the morning of their surgery. This frees a considerable number of bed days for other patients. Furthermore, some patients are channelled through new medical assessment units that complement A&E.
There are now at least two of these working successfully here, at Dublin's St James's Hospital and St Luke's Hospital, Kilkenny. More emphasis was also put on good community care support programmes in the UK to ensure people, who might otherwise have to be admitted to hospital, could be looked after at home.
Gleeson has huge admiration for the families of patients on trolleys at Dublin's Mater Hospital who decided to protest this week at what their relatives had to endure. It has put the problem to the top of the political agenda.
"There has never been a firm commitment from our highest political masters to sort this out," he says. But he believes Mary Harney, with her reputation for getting things done, will move on this problem. Her comments during the week, to the effect that the situation was unacceptable and could not and would not continue, was evidence of this, Gleeson says.
There is, he believes, "a certain apathy among non-A&E staff" about the problem. If he sends one trolley from A&E to a 30-bed ward to relieve overcrowding it's regarded as unsafe and nurses would walk off the ward, he says.
"I can't accept the argument that it is not safe practice to put one additional patient on a stretcher on a ward with 30 patients but at the same time it's acceptable to have 30 patients on trolleys in A&E who should be on a ward, on top of the normal A&E workload.
"The workload, I feel for a long time, should be shared and should be treated as a hospital problem," he says. So high have stress levels become in A&E units that it's becoming difficult to fill consultant posts in emergency medicine. Seven are now vacant.
"Staff in this environment suffer high stress levels and are frequently pushed beyond their limits. And in many cases patients they are looking after are getting sub-optimal care; conditions are misdiagnosed and not picked up. It's laying the door open for legal cases being taken against the doctors and this kind of working environment would not be accepted in any other area of medicine."
Gleeson puts forward two other ideas to relieve pressure on A&Es. These include resourcing primary care and outpatients to cut back on the number of inappropriate attendances at A&E.
Yesterday he came across a man in A&E who had a wrist problem and had been given an appointment to have it seen to in 2006. "He felt it was too long to wait so he decided to go to A&E. That happens all the time."
He believes ad campaigns advising the public to attend their GP rather than A&E are a complete waste of money.
There's no point telling people not to go to A&E if they've no alternative, he stresses, and some people such as immigrants or those in poorer areas have no GP or have no access to a GP at night or weekends.
The Irish Nurses' Organisation, which supported the families who protested over A&E overcrowding outside the Dáil this week, has also put forward a list of things it feels need to happen to address the problem.
Its general secretary, Liam Doran, has called for the chief executives of hospitals and health boards to get involved in sorting out the mess.
He also wants clear admissions criteria to minimise the time a patient spends in hospital before they are treated; ward rounds by consultants three times a day including Saturdays to ensure there are no delayed discharges; more A&E consultants; and the establishment of dedicated minor-injury units in all hospitals.
Furthermore, Doran suggests beds be purchased for public patients in private hospitals at times of A&E overcrowding and that private hospitals establish A&E units to cater for private patients. At present, only public hospitals provide A&E facilities.
But he agrees with Gleeson that in the medium to longer term the situation can only be fully addressed by increasing the number of available beds and improving primary care. That will take time.