Groundhog Day for patients as ‘national emergency’ still drags on 10 years later
From the Irish Independent on 08/01/2016
It’s Groundhog Day for the thousands of patients left waiting in our country’s emergency departments this week. There is a slight improvement, year on year, on numbers presenting to EDs and needing admission to hospital in the last few weeks. But the numbers are way too high and nowhere near where Minister Leo Varadkar wanted them weeks ahead of the next general election.
Fifteen years ago, when the 2001 health strategy was being prepared, more than 1,500 people responded to a public consultation for the strategy. Emergency departments (EDs) (then called A&Es) received by far the highest percentage (83pc) of negative mentions when the public was asked about their recent experiences of the health services.
Action 86 of the 121 actions in the health strategy committed to introduce a ‘substantial programme of improvements in accident and emergency departments’.
There were 10 sub-actions under this heading, some of which were acted on – such as increasing the numbers of ED consultants and better access to GPs out-of-hours. But many others, such as access to diagnostics and improving IT in EDs, were not.
Under Micheál Martin’s stewardship in health, things got worse in EDs as more people waited on trolleys. Weeks after her appointment as minister in 2004, Mary Harney launched a 10-point plan to resolve the ‘A&E crisis’.
Within six months of this, actor Brendan Gleeson spoke angrily on the ‘Late Late Show’ about his parents’ treatment in A&E.
In a tirade against the politicians’ failure to sort out A&Es, he described “the indignity of it as unspeakable … like a military field hospital … a disgrace … it’s a war crime what’s happening in [A&Es] … it’s disgusting that we are allowing people to die when we have billions”.
Gleeson was right. All this was happening under successive Fianna Fáil/Progressive Democrats-led governments when the health budget quadrupled.
Within two weeks of Gleeson’s outburst, Ms Harney declared the A&E crisis was a ‘national emergency’. A year after that, there were more people than ever previously recorded waiting on trolleys in Irish EDs.
Why is it that, more than 10 years on, the ED crisis persists, despite three different ministers, two separate task force reports and hundreds of millions of euros being thrown at the problem?
Much time, effort and money has gone into improving conditions in our country’s EDs, preventing people going there and freeing up hospital beds. But many underlying problems persist and have not been addressed.
EDs still act as the only door into some of our major public hospitals. The use of acute medical assessment and surgical units as well as minor injury clinics needs to be mainstreamed so there are other doors into and out of all acute hospitals.
While there have been increases of emergency medicine consultants, there are still not enough senior decision makers in EDs and across our hospitals, especially at night and weekends. There are not always daily ward-rounds and the absence of consistent discharge planning means patients remain in hospital unnecessarily.
While many consultants work way beyond their contracted hours in hospitals, the absence of information systems means we simply do not know who works, where and when.
Because the incentives are wrong, people keep on coming in the ED doors. Better resourcing of GPs to manage chronic diseases and access diagnostics is required so that fewer people are referred unnecessarily into EDs.
The persistent under-resourcing of primary and community care means people end up in hospital when they should and could be cared for in the community.
Failure to bring down wait times for outpatient appointments and planned hospital treatments mean some of these people end up as emergencies in EDs.
Our growing population is living longer and this is a good thing. But many ED presentations are from the oldest of our old people. Significant increases in geriatricians and fast access to high quality care, preferably outside of hospital or in hospital, without going through EDs, is required for these citizens.
The maximum nine-hour wait time target for people on trolleys in EDs is pure myth.
The clock starts counting only when a decision to admit is made, not when a person presents at the ED.
The vast majority of EDs collect this information (known as Patient Experience Time) from the time of first presentation to either discharge or getting a hospital bed, but conveniently this information is not in the public domain.
We know that doing the same thing over and over again and expecting different results is insanity.
Yet, do we really need more than 30 EDs for a population of less than five million people? Dublin certainly does not need six EDs for its population. A greater concentration of ED resources would facilitate better access and quality care.
But no politician has the courage to raise this thorny issue as it is quite simply electoral kamikaze.
This week’s various media interviews with a despondent Health Minister revealed that Leo Varadkar realises even doing more is not enough.
It is blatantly clear that Groundhog Day will persist in EDs unless much more fundamental reform that tackles the underlying structural causes of ED overcrowding is embarked on.