THE VOX POP on the news the other night had the price of groceries, fuel and housing as the election issues occupying most people’s minds, a single older man mentioned the health service.
Reading some recent headlines in our national papers about the ‘grey’ vote and the importance of the pension issue, it does seem it will ‘be the economy stupid’ here in this constituency too, as it was and always will be seemingly in the US. I’d love to think that for our 2024 election, it might be ‘’it’s the hospital’s stupid’ that might be the defining issue of our election. In many respects, it would be a better consideration for the investment of older people and all of us who hope to live any length of time.
One in four of us will have a stroke, one in 10 will break a hip and over half of us will die in a hospital setting. It might be important then to consider what care you might get and what that care will look like. Currently, our public university teaching hospitals are struggling and for many, it will be a traumatic experience, not just because of the illness, but the environment and mechanics of our creaking public teaching hospital system. From my many visits and chats with staff in our hospitals, I see the challenges of our health estates across the country’s teaching hospital system.
The political solution to our health service is Sláintecare, the somewhat hypocritical illusion of a single-tier health service. Cross-party consensus and all that seems grand, until you ask a politician if they will be using their local public teaching hospital for their own healthcare needs, and then the consensus conviction of a single health service for all, begins to look a little shaky and one gets an awkward mumble or averted gaze.
Health for the political classes is conceptualised as a comfortable private tower, far from the madding crowd.
Sláintecare is about hospitals for ‘other people’ or even worse no hospital, as the system leans and lurches on a gamble on what is termed a ‘leftward’ shift (not a political term I hasten to add) into more community-based treatments. This is good and I’m an ardent fan as a geriatrician of people receiving care nearer home or at home, or receiving care in “the right place at the right time” in Sláintecare speak, except the notion that the hospitals are holding inpatients unnecessarily or that we can treat much more of our emergency admissions at home is a fallacy.
To some extent, the recent unprecedented population spurt has exposed our inability to plan and revealed the inadequacy of our hospital system and the dangers of sole reliance on a community care investment strategy. Our acute hospitals have been left by the wayside as if denizons of healthcare, no longer needed in the smart world of ‘left-shift’ community services, innovation funding and AI.
Yes, we need all those facets but we also need an increase in hospital capacity. Stroke, cancer, trauma, cardiac care and pandemics cannot be managed by ‘integrated this’ and ‘enhanced that’ in the community. The current HSE multi-million euro investment in community models without proper structure, leadership or any auditable meaningful outcome measures, other than the often duplicated and at times, even unnecessary, activity, is hardly an alternative compensation for a functioning hospital system.
Our Government has latterly acknowledged our error in not increasing our adult bed capacity which it has been letting wither for the last two decades, despite the repeated warnings from the Irish Medical Organisation, amongst others. At the time of the pandemic, we had over 2,000 fewer beds than we had in the early 90s. The catch-up will take time and likely be a pocketed approach, but let us a least start to acknowledge the precise nature of our healthcare estate problems.
Hospitals, in case anyone had any doubts, are expensive to design, build and maintain. Heath inflation exists in an ‘upward only’ economic environment as technology and public expectation are unidirectional influences on health spending. Rebuilding a functioning public university teaching hospital system will be expensive and will need continuous fiscal nurturing. The Sláintecare ideology of discouraging a ‘public’ hospital from being able to attract a patient’s insurance income, will not only serve to impoverish that system further from the much-needed investment in infrastructure and technology but also embeds the concept that health insurance is not about social solidarity but rather a privilege.
God forbid a person might decide ‘I have health insurance and want to go to a public teaching hospital where I heard the care is excellent and I like the concept of my insurance money going to a “not for profit hospital” to contribute to the care of everyone’. Heaven shirk at any attempt at a competitive well-funded appealing ‘not for profit’ universal health service. We have an excellent and needed private health service, but it should not be better than our public teaching hospital system, where we train our healthcare staff, which it currently is fast becoming if it’s not already there.
At a meeting recently a colleague described his father’s distress in hospital when hearing someone die next to him on a six-bed ward, an experience healthcare staff struggle with every day in our hospital system. Doctors and nurses spend hours worrying about how someone who is dying can be moved to one of the few side rooms they may have at their disposal. A move that should be routine, but complicated by unavailability, to give patients and their families that dignity without frightening the patient with the move into a ‘special’ room, and to afford other patients the solace of not witnessing death live.
I worry about the psychological trauma of the hospital environment on patients, playing bed moves over in my head so we might be able to make an attempt at some individualisation of care and help people feel safe and secure, within the limitations of space and appropriate beds.
It is a sapping emotion for healthcare staff to be ashamed of the environment where they are trying to ‘heal’ people. A patient’s frustration, sleeplessness, fear and anger are often manifest in our hospitals and impede their recovery or worse.
And the HIQA model of oversight is not a system I would be altogether impressed by. A classic example of ‘regulation makes the compliant more compliant’, HIQA seems more often concerned with the banal than the important. When I asked a HIQA inspector once if he had noticed the lack of space to nurse or toilet people on our six-bedded bays with dignity or prevent infection, he commented ‘That’s not on our list’.
But poor hospital environment has broader effects. Time and again we read troubling stories of the fate of patients because of hospital overcrowding, bringing that issue into sharp focus. As a result of continued exposure to such conditions, staff may suffer from a lack of medical rigour or frank disinterest. They are human.
Imagine day after day leaving work with the moral injury of ‘I couldn’t do my best or help that patient get comfortable, feel better, feel safe’ or ‘that was a really de-humanising experience for that poor patient being incontinent, vomiting, acutely confused or dying in full view of everyone’.
The mounting build-up of this psychological injury is the real cause of the phenomenon of ‘burnout’ in healthcare staff and a major reason why so many of our doctors, nurses, and therapists are abroad in Australia and other countries, so much so that we can’t even provide a minimum of cultural context to the care of older people on our wards. The healthcare staff here are excellent from all corners of the world, and we are fortunate to have them, but it’s also rare to see Irish-trained nurses on our wards since it is so difficult to work within the system where they were trained.
‘A design for older people will include and enable everyone’ to paraphrase the great geriatrician, Bernard Isaacs’ was a call for a non-ageist inclusivity in healthcare and must most critically apply to hospitals. Our public teaching hospitals are old, undersized, poorly designed and not fit for modern healthcare and all that it entails. Our recent experiences with Covid cruelly exposed this.
Our hospitals are not designed for those who most need them, our older age groups, and those most likely to have serious illnesses.
Instead, our hospitals do not hasten recovery but rather decondition older people with trolleys, endless noisy days under glaring lights, immobilised and made incontinent, ‘sit down’, ‘just go in your pad’. We lose their hearing aids, dentures and phones, disabling people and removing their means of communication. We provide wards without privacy or spaces to discuss the most intimate of things, or to be assessed with dignity. Places without TVs, radios, or any form of aesthetic with no room to mobilise or even toilet to get sick in, in private.
These are not the places of care or sanctuary they should be and we wonder why people get confused, depressed, decline cognitively or physically, fall or get infections and end up needing long-term care. Our hospitals have become a Keatsian place ‘where palsy shakes a few sad last grey hairs, amongst the groan and fret’.
Let’s change this. Let’s have a new social contract for our nation’s healthcare. Let’s state that our University and Teaching Hospital system will:
All generations should be invested in this so when it is our turn to need hospital care, irrespective of our income or background, we can have faith in our public university teaching hospital system, which trains our healthcare professionals, to have the best of technology, personnel, design and can meet all our needs, so even our leaders would be happy to be treated there.
If the economy and housing are the issues coming to the fore in this election, then healthcare must be at the top of the list with them. If any of our public teaching hospitals are not as good or comfortable as our private institutions, then they are not good enough.
That must be our standard.
That must be our Sláintecare.
Professor Rónán Collins MD FRCP (Lond) FRCPI FESO is a Consultant Physician in Geriatric and Stroke Medicine at Tallaght Hospital. Follow him @ronancollins7.
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