I’M NOT SETTING myself up as someone who has all the answers. In fact, although I like to think I’m fairly good at what I do in work, I can’t even untangle a set of Christmas lights in less than three hours, and I once needed stitches because I managed to slam the boot of my car on my own nose.
Cleverer people than me will be needed to solve this problem. As I see it, there are a number of things we could do that might get 50 or 60 people a night off trolleys and if we could do that we’d make a big impact on the problem.
1. More beds
Nothing works until this happens. If you had a 400-bed hotel and 40 customers waiting in the lobby every night, you might add a few bedrooms.
Our health service has never recovered from the bed cuts of the late 1980s when more than a million fewer souls lived in the State and life expectancy was 10 years less than it is now. The myth that we have enough acute beds in the system is the Lie Zero of our health debate, the Big Lie on which all other little lies are built.
2. More primary care
Enabling more health and social care, not just medical care to be delivered in the community, won’t fix the entire problem but it could make some impact.
Its main utility is in future proofing the system against anticipated future demographic changes, and supporting our general practitioners who have long been the backbone of medical care provision in our country and are creaking under strains of their own.
3. Changes in how we work
The usual mythmaking here is about getting senior clinicians to see patients on the ward more often, and cancelling elective work to do so.
In reality this makes little or no difference. To use another analogy, if you were running a restaurant and hadn’t enough tables to seat your customers, employing another four chefs in the kitchen isn’t going to achieve a whole lot. Nor will a roast joint cook any quicker for having a chef look at it more often.
Length of stay for medical admissions to hospital in Ireland are very short by European standards, yet because this truth is inconvenient, it’s one you will hear very infrequently by politicians and apparatchiks.
What would help would be a decisive shift towards properly cohorted care. If you come to hospital with liver failure you should go to a ward for liver patients, staffed by doctors and nurses with postgraduate training and experience in liver disease. If this happens you’ll receive better care and be out of hospital faster.
I could frequently have 30 patients under my care with a wide array of problems spread out across 11 or 12 wards. So I might spend an hour a day just walking between wards, being rather unproductive while I do so.
This should be a no-brainer, but it’s hard to implement radical changes like this when the hospital is always over-occupied.
A nurse in an Irish medical ward could easily and indeed routinely find himself or herself looking after a six-bedded cubicle with one patient with heart failure, another with liver failure, somebody with a postoperative drain, a patient with confusion and challenging behaviours, another with an eating disorder and another with advanced cancer.
That they do this for low pay, with little or no audible complaint, is something I find inspiring and is a testament to their seemingly endless commitment and flexibility. But the edges are fraying and nurses can’t be brought into the system fast enough to replace those leaving.
Cohorting wards properly allows them to focus and develop their own practices and careers rather than firefighting on the hoof, day after day, night after long night.
4. Changes in how healthy a set of lives we lead as a nation
1,500 beds a night in Irish hospitals are occupied by the consequences of alcohol abuse. 25% of injuries presenting to Irish emergency departments are alcohol-related. The health service spends €1.2bn per year on alcohol-related harm.
This is not sustainable. I don’t care if they drink more in France or England or wherever. This is our mess and we need to clean it up. That’s not to even mention drugs, obesity and tobacco.
5. Changes in how we use hospitals as a community
In his book, How we die now, Professor Seamus O’Mahony of Cork University Hospital wrote on foot of having had a patient admitted under his care due to his house being redecorated:
If we as a society treat acute hospitals like dustbins, we should not complain if these hospitals begin to look and feel like dustbins. The hospital did not ask for these problems – society was happy to hand them over.
While even discussing this will be controversial (and the problem itself should not be overstated) there is an onus on patients and their families to use the acute service in an equitable manner.
Anyone working in the acute hospital setting will be familiar with the not altogether infrequent scenario where towards the end of a hospital stay a series of demands for consultations, tests and devices are presented to the team as the bounty to be met before the patient will be taken home.
Gaming the system in this manner to jump long outpatient queues makes sense on an individual basis, but the obvious line to be drawn between this conduct and the misery of a fellow citizen allowed to languish another night on a corridor to facilitate it needs to be drawn.
A proper system for prompt outpatient workup and fit for purpose respite and community care services would help undoubtedly, but the harsh truth is that hand on heart in two and a half years in the NHS I didn’t encounter this scenario once.
6. Leadership
I believe Simon Harris is a good man and for the first time in my adult life I have no questions at all over the sincerity and insight of an incumbent Minister of Health. But if we are being honest is health really a live political issue in Ireland?
When I lived in the UK and US healthcare debates were a major framing point of general and presidential elections. Without looking it up could you write 100 words on the healthcare plans of any of the four major parties? Me neither. 10? Nope. But I bet you know exactly where they stood on water charges.
Innovative and daring medical, nursing and managerial leadership is also sorely required. And here we all have a part to play. Doctors are far from blameless. As a group we can be conservative, dreary and sometimes reluctant to change.
The important thing is that it can be done, it must be done and we have to believe that.
Dr Anthony O’Connor is a consultant gastroenterologist in Tallaght Hospital. Cork-born, he trained in Tallaght and St James’s Hospitals in Dublin before doing an advanced fellowship in Boston USA and subsequently as a consultant in Leeds, UK before returning to Tallaght in 2016.
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