An Unhealthy State: Most hospital doctors are under-trained and many hospitals are ill-equipped, Maev-Ann Wren writes in the third part of her series
In September 1998, a man died in the operating theatre of an Irish hospital - in itself not unusual. The hospital staff had done their best to save him. What was unusual was the series of events preceding his death, which had taken place in another hospital, from which he had been transferred. It was sufficiently unusual that the dead man's family asked the Ombudsman to investigate.
Following a detailed inquiry, the Ombudsman concluded that his care in the initial hospital had been inadequate. Although precluded from commenting on the exercise of clinical judgment, the Ombudsman nonetheless recommended that the health board, hospital and medical staff should bring "greater clarity to the working relationships between junior and senior medical staff".
There is a danger zone, a terra incognita, in many Irish hospitals. This is where patients are left to the care of junior doctors, under the nominal but absent supervision of their superiors. Most dangerously at weekends. This man's condition deteriorated on a Saturday. By Sunday evening, he was dead. Over Saturday evening and night he had been under the care of an orthopaedic senior house officer (SHO) - assigned on a six-month training rotation - a junior doctor who had been on call continuously from 9 a.m. on Saturday and would remain on call until 9 a.m. on Monday, when he was due to start a normal 9 to 5 shift.
The patient had been admitted on the preceding Wednesday, following a referral by his GP for assessment of lower back pain. He had seen an orthopaedic consultant, who went off duty for the weekend. As the patient deteriorated, the consultant was never contacted.
In the hierarchy between him and his struggling junior was another more senior non-consultant doctor, the orthopaedic registrar. Not until Sunday morning did the SHO tell the registrar that he had concerns about the patient. The registrar was knowledgeable enough to realise that the surgical team should immediately be involved.
The surgical SHO later telephoned the locum consultant surgeon on duty, who recommended the patient's immediate transfer to a neighbouring hospital which had a vascular unit. It had become apparent that the back pain was a manifestation of a vascular problem, later identified as an aortic aneurysm or swelling of the aorta, whose eventual rupture killed the patient.
In constituencies throughout the State people have fought for the retention of small local hospitals, for care as close as possible to home - but care of what quality and delivered by whom?
When last December Monaghan Hospital sent Denise Livingstone in an ambulance to Cavan, even though the birth of her baby was imminent and consequently took place at the roadside, she had been assessed by a surgical SHO, the most junior level of doctor, who did not realise that she was in labour, as he testified to a review panel established by the Minister. He was also unaware that nurses believed her to be in labour - a "communication deficit" which might have been resolved by the involvement of a consultant, a health board review suggested, but a consultant was never called.
In September 2000 in St James's Hospital in Dublin 76-year-old Josephine Hanbury was brought by ambulance to A & E with severe abdominal pains and was soon vomiting blood. It was Saturday evening - terra incognita - and at 3.30 a.m. on Sunday, after being seen by various junior doctors, she was sent home. At 9 that night she was readmitted. When a consultant surgeon finally saw her on Monday morning, he immediately sent her to intensive care. She died on Wednesday following surgery for a perforated ulcer.
The coroner noted at the inquest that the hospital had introduced a policy that no patient in a similar situation should be discharged without a review by a senior surgeon.
Most patients when they go into hospital expect to be in the care of a fully-trained doctor, but this is frequently not the case. Almost a quarter of patients surveyed last year said they rarely or never saw their consultant. In 2002, Irish public hospitals employed 1,731 consultants and 3,932 non-consultant hospital doctors (NCHDs), of whom 2,145 were interns or house officers, generally in their first three years after leaving medical school. These SHOs typically move from hospital to hospital every three to six months in training rotations.
The remaining NCHDs were registrars, of whom 593 were "specialist registrars" in formal post-graduate training, while the other 1,193 were not in recognised training posts. The majority (77 per cent) of the specialist registrars were Irish, while 72 per cent of the registrars who were not receiving training were not Irish, and most were from outside the EU. They were in dead-end posts which Irish doctors would not fill because without post-graduate training they would never get the only permanent hospital position available - consultant.
Non-EU doctors nominally come to Ireland to train. In reality, they have been "propping up the hospital system", in the words of Prof Gerard Bury, president of the Medical Council. A 1995 survey of house officers and registrars found that 57 per cent were not in training schemes, 50 per cent considered their training "less than good" and 68 per cent did not know whether a particular person had been designated as being responsible for their training.
The Medical Council has been using its power to regulate the training of non-EU doctors to insist that they should be in accredited training posts. However, in small hospitals with a low throughput of patients, training may simply not be possible.
Meanwhile, EU rules require a progressive reduction in the hours worked by junior doctors. The resulting shortfall in medical staffing could be made up by increasing either the army of immigrant doctors or the number of fully-trained consultants, and ensuring that they are available to public patients. But increasing the number of NCHDs would mean that the treatment of patients would "increasingly be delivered by doctors not yet sufficiently qualified or experienced in their work", as the imminent report of the Hanly task force on medical staffing comments.
This Government-appointed task force has concluded that the alternative - a "team-based consultant-provided service" - is the only way to ensure "high-quality, safe patient care". Achieving this will require a doubling of the number of consultants over the next 10 years and nearly halving the number of NCHDs. It also necessitates ending the fiction that it is possible to provide quality, acute care in every county.
This fiction costs lives. "It is almost certain that people are dying from road traffic accidents who should be saved, and the proportion is probably quite high," according to Niall O'Higgins, UCD Professor of Surgery. Bringing severely-ill patients to unsuitable hospitals had not only resulted in avoidable deaths but also in long-term disability with its economic, human and personal costs. "There is absolutely no doubt about this. We see it all the time - people coming into our hospital (St Vincent's in Dublin) who have been brought to another place where the standard of care is less and where they have not been treated well."
Hanly has recommended that acute care should be concentrated in large regional hospitals, while the smaller hospitals, the Monaghans, should no longer treat major traumas or medical emergencies. They would host out-patient clinics and offer elective surgery, mainly on a day basis. Only low-risk patients would stay in these hospitals overnight. The reality is that it is not feasible to provide round-the-clock consultant cover in every small hospital.
The hospital system's dependence on junior doctors is not just unsafe for patients but also wastes state resources. Hanly records how, with overtime, the average earnings of a registrar last year were€121,709, and of a senior registrar €157,529 - more than fully-trained consultants' earnings in many countries. Yet registrars work in what an early draft of the report described as a tiered on-call system of "serial failure" in which patients are referred up the line for diagnosis through ranks of junior doctors until finally their case receives the attention of someone qualified to take appropriate decisions. While later dropping the reference to "failure", Hanly still proposes that consultants should now be either first or second on-call.
Hanly retreads the ground of the 1968 FitzGerald report, whose recommendations for the rationalisation of hospital services outside Dublin have never been implemented. Attempts by Labour's Brendan Corish in the 1970s were defeated when Fianna Fáil chose to foment local opposition. Attempts by Labour's Barry Desmond in the 1980s ran aground when the Supreme Court ruled that while the Minister might close a hospital, he did not have the power to order it to cease certain services.
No Government has since changed the law to give the Minister this power. Decisions on hospital services have been left in the hands of councillors on health boards, who in the absence of local taxation have every reason to vote to retain local services. This failure of the political system to ensure safe, quality care is the main indictment of the health board system. The strongest argument for its abolition and replacement by a national executive answerable to the Minister is the argument for safer patient care.
Tomorrow: The promotion of private hospitals
Maev-Ann Wren is the author of Unhealthy State - Anatomy of a Sick Society, published this week (New Island, €17.99)