Short-term strategies can be used pending a more lasting solution to worsening crisis, writes Dr Muiris Houston.
Last weekend, relatives of patients awaiting treatment at the Mater Hospital felt compelled to stage a public demonstration outside its front gates to highlight the appalling conditions in the accident and emergency unit. Protesters held placards aloft bearing slogans such as "Stay at Home - You'll Die in Comfort" and "It Could Be You". They were stark reminders of the substandard conditions countless patients endure not only in the Mater, but in many other overstretched accident and emergency units throughout the State.
In terms of yesterday's newspaper headlines, it was always a case of when, rather than if, they would appear. Accident and emergency departments experience much greater demands in the period October to April. This is because of what healthcare workers refer to as "clinical winter" - the months when viruses and other infections lead to greater amounts of respiratory illness and when patients with chronic ill-health get tipped into acute illness by the drop in temperatures and other factors.
With both the overall population and the percentage of those greater than 65 increasing every year, this annual surge in demand will increase inexorably. However, in the absence of an increased number of beds - it is accepted we need 3,000 additional acute hospital beds - the effect is to squeeze a quart into a pint bottle. Delays in A&E departments, especially in Dublin, are inevitable.
It is clearly wrong for anyone to spend longer than 12 hours on an accident and emergency trolley waiting to be moved "up the house" and into a proper ward. The fact that this wait is routinely in excess of three days means our health service resembles that of a developing country, rather than one that reflects our recent economic success.
The Tánaiste and Minister for Health, Ms Harney, has acknowledged the depth of the A&E crisis and has pledged to make it one of her priorities. So what can she do to alleviate the problem?
Firstly, she must differentiate between the accident and emergency departments in Dublin and other major cities and those of regional hospitals throughout the State.
Ms Harney can streamline the functioning of these hospitals by expanding the concept of the medical assessment unit (MAU), already successfully operating in Kilkenny. Patients identified by GPs in the Carlow/Kilkenny area as being in need of acute medical care are referred to the MAU of Kilkenny General Hospital. When they arrive, they are examined by junior hospital doctors and nurse specialists before the consultant-on-call arrives to assess the patient. Once a decision to admit the patient is made, treatment starts immediately and the person will routinely find themselves in a proper hospital bed within three to four hours of arriving at the hospital.
The MAU complements the accident and emergency department; a crucial point, however, is that an experienced GP has already guided the patient to the MAU as the best place for them to be assessed and treated.
While new MAUs may ideally require new structures to be built, it should be possible to set them up in areas adjacent to current A&E departments in the short term. So following a ministerial directive, and with the co-operation of hospital consultants, nurses and hospital managers, MAUs represent a relatively "quick fix" solution for Ms Harney.
Why not do the same in Dublin and other urban areas? One of the reasons such units work in smaller hospitals is the availability of long-term beds in former county homes and other institutions dotted around the Republic. This means it is generally easier to discharge older patients from acute hospital beds in smaller regional hospitals.
Which brings us to a key element in solving the urban A&E crisis. There are approximately 300 people inappropriately occupying acute hospital beds in the greater Dublin area. These patients no longer require acute hospital treatment; however, neither are they fit enough for discharge home. So there is an urgent need for Ms Harney to find a solution to the bottleneck that results. She must find a way of moving such patients to nursing homes and long-stay beds, thus "creating" 300 extra acute hospital beds without actually adding to the current bed stock.
With some changes to the nursing home subvention scheme, and a concerted effort, this can be done. The beds for these patients already exist in the private nursing home sector. What the Minister must do is create a steady flow of patients into these beds.
Another problem in the Dublin area is that the hospitals in the capital act as tertiary as well as secondary treatment centres. This means they provide "super-speciality" services to patients outside their natural catchment area. Beds need to be kept free for these services, which means there are less available for the acutely ill patients arriving at A&E. Solving this issue represents a medium- to long-term challenge.
The Minister cannot tackle the accident and emergency problem in urban areas without looking closely at what happens in primary care. GPs in Dublin tend to farm out their out-of-hours services to on-call agencies rather than form co-operatives, as their rural colleagues do. This means that patients face considerable delays in being seen and are likely to be assessed by a locum doctor without access to their medical history. As a result, referral rates to hospital tends to be higher. In addition, patients are more likely to bypass the locum agency and self-refer to hospital. The cumulative effect is for larger number of patients to flood accident and emergency departments, especially in the greater Dublin area.
Again, changing this scenario is not a realistic challenge for the short term. But Ms Harney cannot ignore it and must give priority to changes in general practice outlined in the Government's Primary Care Strategy.
Would increasing the number of medical cards help? It may have an indirect effect, in that those just over the present threshold are actively avoiding GP visits because of the huge dent in their weekly incomes caused by a visit to a doctor and the subsequent pharmacist's bill. It may be that these patients are instead going straight to the accident and emergency department, although there is no evidence of such a pattern to date. However, what is clear is that low-income families are more likely to embrace preventative treatment of chronic illness when they have a medical card. This should, in theory, mean they have a lesser need for emergency care.
The scenes outside the Mater Hospital will be repeated elsewhere in the coming months.
To what extent they do is now in the hands of Ms Harney and the short-term strategies she outlines in the weeks ahead.