Hospital consultant 'Everyone in medicine dreads the Friday night on call for the same reason'

THE MINISTER FOR Health was critical in recent days of the number of hospital consultants who were working over the most recent bank holiday weekend. 

Figures showed 10% of consultants were rostered either on-call or on-site in a sample of Ireland’s hospitals. “This is not enough,” Jennifer Carroll MacNeill said. 

The Minister is right about the health service needing to operate on a seven day basis and the need for senior clinicians to be available. Not primarily for the trolley crisis though, in my opinion, but rather for patient safety: many of the significant healthcare decisions are made in our emergency departments by relatively inexperienced doctors.

Medicine is complex and not mathematical – no-one gets every case right. While AI isn’t quite there yet, the best intelligence currently available is an experienced clinician with thousands of data points of pattern recognition over many years. It often surprises me when things go wrong why a coroner’s inquest doesn’t examine medical experience as potential factor in poor clinical outcomes. In my experience of these, a common factor in a majority of cases has been the lack of a senior oversight at an early stage. That should be the real reason for advocating for more senior decision making on a seven-day basis.

But having more consultants available at the weekend is unlikely to solve the trolley problem. There is little fat on the bone now in our health service. While there might have been the odd ‘soft’ admission in the past, from my recent experience on general medical take almost all of the referred patients need admission.

There is a real lack of services across the board at weekends

In fact at times decisions to discharge patients can seem to lack empathy or be agnostic of a patient’s realities in the desire to discharge. Those that might get home with the benefit of my decision-making experience are unlikely to do so without the necessary diagnostics, IT infrastructure and community support structures also working to make this happen.

MRI -  a necessity in healthcare -  does not operate in most of our teaching hospitals at weekends and there is no access to important health and social care professional ‘diagnostics’ like a physiotherapy assessment or social work review. Modalities like ultrasound and echocardiography are generally not available at weekends either. A misguided solution to address some aspects of this has been to expensively outsource, rather than building internal capacity.

Our IT infrastructure, while improving, is still pretty disjointed and creakingly slow. We cannot see what happened when the patient before us was recently admitted to a nearby hospital or cancer centre. This will often lead to duplication of diagnostics in a rather  perverse efficiency to achieve a timely discharge.

There is often no primary care centre to contact at weekends to ask ‘could you monitor Mrs X for a day or so because we think she’ll be okay but could deteriorate’, nor a mechanism for real-time sharing of results with our GP colleagues. A ‘failed’ discharge due to a patient becoming unwell again is often likely to lead to an angry complaint from family, though this is the reality of how medicine and human beings work. There is no 100% guarantee and we need an understanding of the concept of appropriate risk as a society. We don’t do appropriate risk in Ireland.

There is next to no hope of contacting care services to restart older people’s care packages at the weekend, or getting access to timely rehabilitation in the community – despite an almost €60 million investment on ‘enhanced community care’, a programme without any meaningful metric of outcome to my eye, apart from ‘patient contacts’.

Patient contact in itself, while often well received, may conversely add to the workload of an already overburdened system, duplicating assessments and interventions, but not really altering outcomes. Integrated care remains a real challenge in Ireland.

The human factor that has to be borne in mind at weekends

The Minister has rightly noticed that long weekends tend to cause spikes in activity (though curiously not as much so in summer months in my experience). We have high circulating levels of infection right now and curiously people often wait to the end of the week to see ‘how they are going’ before chancing the weekend at home when they know GPs or community supports may not be as available to them.

Families may have other plans and are not able to support an older relative at the weekend. These are real human factors.

Everyone in medicine dreads the Friday night on call, not because we don’t like working weekends – I’ve worked weekends all my life – but because it’s generally much busier and harder to do one’s job without all the other services also operating.

Similarly older patients can be superstitious still about Saturday discharges and refuse to go, or families whose support for the discharge decision is usually needed may raise objections. Such objection is often from a mistrust in the aftercare – and not always misplaced either. Navigating how far to ‘push’ and cajole can be a dark and tricky art. The stakes are high. Complaints can be frequent. Accusations of ‘pushing my father out’ often accompanied with threats of reporting one to the Medical Council or suing if it goes awry are occasional but very unsettling.

Minister Carroll MacNeill and others have previously cited hospitals like Waterford as exemplars and others like University Hospital Limerick (UHL) as laggards in the war on trollies. Such an approach to analysis is trite and simplistic. It’s also not helpful, apart from blowing off some political steam.

Hospitals have different catchments. For example, my own in Tallaght has very different challenges demographically compared to St Vincent’s in Dublin 4, where our patients are less affluent, rapidly aging, and with a larger population of nursing home and refugee residents.

Others like UHL have had the closure of acute facilities in their catchment area at Nenagh and Ennis, or in the case of Our Lady of Lourdes Hospital Drogheda, the closure of Navan. In both cases the rise in inward traffic has been substantial. The bypass of acute stroke services to Tallaght from Naas has similarly increased inward flow. None of these service reconfigurations or demographic shifts are measured or resourced.

‘There is no loaves and fishes when it comes to hospital capacity’ 

Similarly, if you concentrate purely on trolley wait times then something has to give. Waterford may have great trolley metrics but it had some of the poorest rates of admission of stroke patients to an acute stroke unit. The hospital in the glaring spotlight of a ‘trolley watch’ has prioritised trollies over acute stroke care. It’s natural: there is no loaves and fishes when it comes to hospital capacity.

When I worked in the NHS I saw the danger of trolley wait initiatives. My caring giant of a hospital got hit with a national dictat of a four-hour trolley wait imposed as a key performance indicator.

The net result was premature discharge or the transfer of patients to a far-off ill-equipped ward. In at least one case I witnessed the probable unnecessary death of a young woman due to such a move. Watching the national machine roll on with ‘nothing to see here’ was a lesson for me. To this day I don’t know if that young husband ever knew what actually happened to his wife. My supervising consultant raised very significant concerns, the result of which seemed to be her removal from the duty roster. ‘Don’t mess with the system’ seemed to be the message.

I hear the band starting up this tune here with the tone of recent interviews about the Irish health system. ‘Meeting the target and missing the point’ as one learned review of another NHS institution summarised, can be a real dangerous trap.

‘If we want a seven-day system we need seven-day services’ 

Part of the current frustration evident with the persistently high numbers on trolleys comes from the belief that the new consultant contract would sort this out – which of course it won’t, not as sole measure. Health systems are complex and need all parts communicating and working in tandem.

If we want a seven day system we need seven day services, and the services must all move en masse to this working pattern.

The new consultant contract was never going to address the trolley problem. I was amazed at the naivety of thinking here. For a start, the majority of consultants are not doing acute general internal medicine, and that is what generates the trolley numbers in the main.

Working weekends without other functioning services is meaningless to the system. The surgeon who has no beds or theatre space due the focus on trollies still cannot operate and sits frustrated in the coffee room after telling her cancer patient for the third time the operation is cancelled and they must make the long track home to the midlands. Ironically, this unintentional victim of our focus on trolley counting will soon end up as an emergency trolley admission in the emergency department – and the patient suffering and waste of manpower is not captured in any metric.

We have a significant job to do to address the hospital capacity and poor infrastructure with our both burgeoning and aging population and while we await the capital investment so badly needed and neglected for too long, here are a few challenges the Minister might consider addressing with us involved in healthcare first, rather than risking the demonising of any one sector of the health service:

• Build the capacity in emergency medicine so that all patients being referred for a hospital admission have a senior review for safety of care and appropriateness of admission. Our emergency departments could be much more than just triage systems

• Ensure we have a functioning primary care service on Saturdays at least

• Make community social care services a seven day service and set timelines for delivery of packages of care that have financial penalties if not met

• Ensure MRI access on site in all our acute teaching hospitals at weekends with agreed criteria for access

• Ringfence urgent care beds like stroke units and emergency surgery with practical standardised operating procedures, to enhance patient flow and outcomes, avoiding longer lengths of stay, unnecessary over investigation and eventual readmissions

• Invest in evidence based models of community care like early supported discharge rather than guess–investments

• Commit to re-creating the teaching university hospital system that has public trust, chosen for its excellence and resourced to develop and invest in meeting healthcare needs of everyone and supported by those of us with health insurance when we need it.

Professor Rónán Collins is a consultant physician in geriatric and stroke medicine at Tallaght University Hospital