New year, new records in our dysfunctional emergency departments
There were reasons to be weary at the latest meeting of task force set up to deal with the perennial trolley crisis
IT was an emergency meeting with a distinct lack of urgency, according to one attendee. Gathered around a conference table at Dr Steevens' Hospital, Dublin, the headquarters of the Health Service Executive, last Friday were directors of the public health service, union leaders, representative groups for consultants and GPs, the ambulance service and a single patient representative, Stephen McMahon. Beside him sat Minister for Health Simon Harris.
Liam Doran, the head of the nursing union, the Irish Nurses and Midwives Organisation, later said he found the meeting to be "underwhelming", "more of the same", and "frustrating".
There were reasons to be weary. The meeting was the third since September of the Emergency Department Task Force. The group was set up by then health minister Leo Varadkar in December 2014 with the attention of knocking heads together over the perennial crisis in the health service of overcrowding in hospital emergency departments.
But, as the pile-up of ill patients on trolleys showed last week, the group failed to deliver. On the first day of the New Year, Cork University Hospital warned patients to stay away from its emergency department such was the surge for treatment.
By Tuesday, a record of 612 patients were backed up on trolleys and in wards across the country's emergency departments. By Friday, the backlog had eased to 395 patients, 260 of them on trolleys.
Most of those around the table have seen it all before, the same cycle of winter, community-borne infections, the surge to the emergency departments, the pile-up of patients on trolleys, the operations cancelled, the rush to find step-down beds, the public outrage, ministers vowing to enforce reforms.
However, it's all new to Harris, who turned 30 in October and is faced with his maiden crisis in his first year in the job. Varadkar's legacy to patients on trolleys is the Emergency Department Task Force. The legacy of Varadkar's predecessor Dr James Reilly was the special delivery unit dedicated to making hospitals more efficient. But Harris is going after the managers.
Ahead of the task force meeting, leaked details emerged of a strongly worded letter Harris wrote last week to Tony O'Brien, the HSE's director general, telling him to hold managers accountable and to sanction staff who underperform.
At the meeting, Harris kept up the assault. He wanted to know how had the health service not anticipated the crisis and who was responsible? "He went on for quite some time about it," said McMahon, who sat beside the minister at the meeting. They were singing from the same hymn sheet.
Afterwards, the health minister told reporters that the health service "wasn't adequately prepared, and that's not apportioning blame, it's stating what's now the obvious this week".
Going after the performance of hospital managers may give Harris some political cover - targeting faceless, fatcat health management hits the populist note. Especially as money has yet to solve the problem.
The health service received a record budget of €14.6bn this year and €40m was ring-fenced to keep patients off trolleys. This failed abjectly.
Overcrowding crises have dogged emergency departments since the inception of the Health Service Executive in 2005 and for many years before that too.
Every winter, a surge of patients turn up at emergency departments, usually before or after Christmas. On Christmas Eve, however, there were only eight patients on trolleys across the entire country, according to HSE figures
Most hospitals don't have the beds or the staff to treat the annual surge of patients Many patients wait hours or days on trolleys or in wards, to see a doctor or often for something as simple as a scan or an X-ray because diagnostics usually stick to office hours.
Every year brings a new record in the numbers of waiting patients. This time last year, the record for a single day was 601. This was broken last Tuesday by the 612 patients.
Much of the problem is historic. For years, Ireland's health service was under-resourced. Beds that were lost during the lean years of 1980s have never been re-opened.
The austerity years and the moratorium on hiring has led to a nursing shortage and there is a corresponding shortage of consultants. There are fewer GPs, there is a growing population and, more importantly, a growing ageing population, that has proved to be an enormous burden on the health services.
Various governments have spent tens of millions of euro, drawn up plans, initiatives and efficiency drives and attempts at joined-up thinking, to speed up patient throughput in A&E departments.
The figures show that none of it has worked. In 2006, a total of 55,720 patients waited, most of them on trolleys, for treatment at emergency departments. Last year, 93,621 patients waited.
Professor Michael O'Keeffe, a consultant ophthalmologist at the Mater Hospital, in Dublin, a long-time critic of inefficient hospital management, believes this is because the public health service is "dysfunctional at every turn", from the phone service up.
"The basics don't happen. Have you ever tried ringing a public hospital for an appointment? You get a message saying please don't leave a message on this phone," he said. "If your appointment is cancelled, you don't know when it's going to surface again. That's been going on for a long time. These are not funding matters, this is not a case of throwing money at it."
There is a fundamental problem of a shortage of hospital beds, and with it, chronic staff shortages. But he also talked about a "crazy", "off-the-wall", "mad" system in which appointment lists are cancelled, patients wait months for another, there is no communication and hospital answering machines don't allow callers to leave a message. "It is an ongoing chaotic situation," Prof O'Keeffe, who works in public and private practice, said. "It is crisis management and it has been for some time.
"In the private hospital, if I don't see patients, I don't make any income. If that happens, the hospital will lose money and go out of business. In the public hospitals, nobody cares if you turn up and see 50 patients or 10, or do 50 or 100 surgeries or 10 surgeries, nobody cares, nobody checks it out. That's the difference, because you have a job for life.
"The less you cost the hospital budget, the less they care. Unless and until you change that whole approach and attitude and make it more accountable, I think it will go on and on the way it is.
"Why don't we get a few managers into a hospital and say, 'You make sure the phones are answered, you make sure the lists are running on time, you make sure they're not cancelled, you look at targets in individual departments and say you have got to meet them, you look at doctors and say why aren't you turning up to your clinic'? And then you'll get something going.
"A lot of hospitals need a boot up the backside and a lot of them need to be shaken up and run properly. It is frustrating. There are a lot of good people in the public system, but boy, does it need a change in the system, a change in mentality and a change in how it's run."
Despite the despair about a creaking health service on its knees, some hospitals have made significant inroads on overcrowding in their emergency departments.
In recent months, the figures collected by the INMO for the numbers of patients awaiting treatment on trolleys and in wards across the country's emergency department have shown improvements in some Dublin hospitals such as Beaumont, Connolly and St James's, and in the South East.
For instance, this time last year, Beaumont was at the top of the list for emergency overcrowding. One of the busiest hospitals in the city, the north Dublin acute hospital also has one of the biggest populations of elderly people in its catchment area.
In 2015, a total of 8,243 people waited on trolleys. Last year, that figure dropped to 6,130. Last Friday, 22 patients were on trolleys - 22 too many but an improvement on the record of 54 patients on trolleys in January last year.
How did they do it? At Beaumont, many credit Ian Carter, the head of the RCSI Hospital Group, who took over as chief executive of Beaumont Hospital last June. Carter used to run the Special Delivery Unit, which was Reilly's answer to the trolley crisis and waiting lists when he was health minister.
The unit was intended to help hospitals become more streamlined and efficient in getting patients through the system. At Beaumont, it appears, Carter is practising what he preached.
Professor Bill Tormey, a consultant at Beaumont and a former councillor, outlined a co-ordinated team approach, involving hospital consultants, nurses, social workers and nursing home managers.
Each morning, doctors meet for a "morning report" when patients in the emergency department are assigned care teams. "Those who need to be seen by specialist consultants go to cardiologists or geriatricians, and the rest are parcelled out to each team that's on call, so that no one finishes up with 40 patients," he said.
Emergency patients are seen faster. Consultants do ward rounds twice a day, admitting patients and discharging those fit to leave - this is not new but is now "happening rigidly," Tormey said. Patients are assessed for discharge after seven days, so decisions are made early as to what is needed, whether a step-down bed, a home care package or otherwise.
A geriatric consultant is to be appointed and based "in the community", the plan being that he or she will see and assess elderly patients before they ever get to the emergency department. The hospital has also benefited from extra transitional care beds for elderly patients to be discharged to, and rapid access to home-care packages.
The measures are not radical or revolutionary. Many of them are taken from the HSE's own Emergency Department Task Force action plan, published two years ago but yet to be properly implemented, pending talks with doctor and nursing associations.
But Tormey said the improvement measures have been "transformative".
"It has turned Beaumont from a whole series of inter-related medical practices to a team practice," he said. "It just means that Team Beaumont is behaving like Ireland does when Joe Schmidt gets all the bits together."
Problems still plague the hospital. It is still massively short of beds and the INMO reckons that Beaumont needs 100 nurses - a figure the HSE may well dispute. Staff are under pressure.
Lorraine Monaghan, the INMO's representative for Beaumont and Connolly hospitals, said there are still huge problems with bed and nursing shortages.
"There is a focus on reducing the length of stay of patients, so everything is moving at a faster pace," she said. "Everything is moving at a faster pace, but this is putting massive pressure on staff in the wards because they are dealing with an increase in the turnover of patients."
The HSE said last night that it will review patient safety and mortality data across emergency departments to mitigate risk and improve patient safety.