The solution to our overcrowded hospitals may not be an obvious one, but we must keep trying
10 July 2006
On Wednesday, 26 April 2006 there was a useful letter from Frank Bannister in The Irish Times regarding the Accident and Emergency (A&E) crisis:
"Madam,Let me see if I have this right. The problems in hospital A&E units can be solved if there are more hospital beds or consultants stop blocking hospital beds or elderly patients stop blocking hospital beds or there are more step-down care facilities or there are more A&E consultants or consultants work more flexible hours or consultants work longer hours or procedures in A&E units are improved or more people go to their GPs first or more GPs are available at anti-social hours or there is less alcohol abuse on weekend nights or the Government pumps more money into the health service.
That seems straightforward enough. Should be sorted out in no time.
Yours, etc,"
Recently some members of the Irish Hospital Consultants Association came before the Joint Oireachtas Committee on Health and Children to discuss the Accident and Emergency Service in this country which even the Tánaiste and Minister for Health and Children, Mary Harney, admits is in crisis. It was a useful meeting, much helped by the fact that Dr Jimmy Devins, TD acted as chairman (or referee), his knowledge of hospital life keeping the proceedings civil throughout. The opening speech by Dr Josh Keaveny in which he said he was fed up, or words to that effect, of politicians criticising hospital consultants was immediately challenged by Senator Geraldine Feeney. She, having served on the Medical Council of some years, knows more hospital consultants than some other committee members and she asked Dr Kearney to name the politicians. No names were given and we returned to the A&E crisis leaving the politicians on the back burner.
Between them Dr James Binchy of University College Hospital, Dr Gerard Lane of the Letterkenny General Hospital and Dr Gerard McCarthy of Cork University hospital gave the committee members useful insight into what they as consultants see as the problems in A&E departments. It was not so much the people who were coming into the A&E that were the problem as getting those who required admission out of it due to the lack of access to the inpatient facilities in the hospital. That is what is causing the chaos in their departments. Drunks were not as serious a problem as politicians like to describe them and certainly some, it was pointed out, needed medical attention. One member of the committee seemed to query how deserving of treatment these people were but the consultants, quite rightly I feel, were adamant that they would be given the medical treatment required.
Like Dr Devins I have worked in hospitals and it does seem mad that patients who need admission in the opinion of experienced GPs have to be sent to A&E rather than straight into hospital as they were until ten or twelve years ago. This is a terrible waste of time and money and should be a cause of great concern. These delays cannot help the patients but with bed occupancy at 100 percent and more these already diagnosed patients have to fight it out with accident cases and so forth for a bed.
1991, we were told, was the first time there were complaints about patients being kept on trolleys. Some of the staff in the A&E in the Meath Hospital wrote to the consultant in charge of A&E, Dr Geoff Keye, complaining that they were obliged to keep three, as I remember, patients on trolleys overnight because there were no beds in the hospital into which they could be admitted. Those were also the days which followed the closure of Dr Stevens' Hospital. When the board of that hospital complained in 1989 that the budget to run the hospital was inadequate the Department of Health's response was to close it. Anyone who can remember the hospital will be well aware of the amazing amount of work that went throughout the A&E there as well as the inpatient wards.
There are surveys which the consultants quoted which show that the length of time spent by a patient in A&E is directly proportional to the bed occupancy of the hospital. One particular paper they quoted "The association between hospital overcrowding and mortality among patients admitted via Western Australia emergency departments" published in the Medical Journal of Australia Vol 184 Number 5. 6 March 2006 was very worrying. Increased mortality results if the admission of patients from A&E is delayed due to hospital overcrowding. The excess mortality could be 20-30 percent.
Bed occupancy should be about 85 percent to allow for proper cleaning if nothing else. Infections spread in overcrowded areas. The number of community beds in the country has been dropping since 1997. If patients are not well enough to go home (home helps are "dropping", too) or go to a nursing home they surely have to stay in that bed in the acute hospital. More women working outside the home to increase the prosperity of the country means they can't take on the home nursing role women in the home had in the past.
While these beds are occupied by people who could be discharged those who need admission from A&E wait on trolleys, three days in the case of a friend of mine who had a stroke. And into the bargain elective operations are cancelled. A constituent of mine had her admission cancelled repeatedly for an operation for "an ovarian tumour". As I write I don't know if she was eventually admitted to either of the hospitals in which her gynaecologist worked who in despair had put her on two lists. Apparently one hospital which the Tánaiste said had little problem with trolleys in A&E, apparently achieves this situation by cancelling most of the ENT surgery there, which is not a useful way of progressing work.
Dr Paul Browne, chair of the Medical Board at St James' Hospital and Mr Finbar Fitzpatrick Secretary General of the IHCA attended, too. Amongst the useful information they gave the committee was the fact that we have 3 acute beds per 1,000 population (there are 3.5 in the UK and 4.1 in the OECD area). So we are trying to manage with fewer beds in acute hospitals and a reduction in those we have in the community.
The building of private hospitals on eight sites of public hospitals is apparently going to solve all. It was a relief to me to see that none of the IHCA members were any clearer than I am as to how these hospitals are to be staffed. The consultants in the public hospital will work only in the public hospitals. Some other consultants who will not work in the public service will work in the private hospitals. But there will only be 100 beds in each of these private hospitals and to cover all specialties they will need a considerable number of consultants and many other staff will be required. Will facilities and equipment be duplicated in the public and private hospitals? If not who will look after patients that have to be transferred from the private to public facilities such as Intensive Care?
Go back to Mr Frank Banister's letter. The solution is in there somewhere but I can't help but think we're not finding it.
Senator Mary Henry, MD
