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Wednesday 4 October 2023 Dublin: 12°C
Hospital consultant 'I'd like to dispel a few myths for people about overcrowding'
It’s a hospital overcrowding problem that has been decanted into the Emergency Department, writes Dr Anthony O’Connor.

I AM A doctor and I work as a consultant in a large hospital in Dublin. I am lucky and proud to work as part of a dedicated and effective team in what I truly believe to be a fine hospital, where 96% of patients last year describe the care they received as good or excellent.

I qualified to work as a doctor in 2004 and since then, apart from a 3 and a half year hiatus while working in the US and the UK, I have spent large parts of my days in various hospitals across Ireland apologising for delays in care, both inpatient and outpatient.

The bottom line is that the system nationwide does not quite have the capacity to deal with the demands placed upon it. This does not make us unique, and I’ll expand on that but as you will know, it tends to generate a lot of comment in Ireland, usually focusing on simple solutions that the latest talking head heard from someone who knows someone who read something once.

So, I would like to try to dispel a few myths for people reading about overcrowding.

1. This is an Emergency Department overcrowding problem

No. It’s a hospital overcrowding problem that has been decanted into the Emergency Department. Patients boarding overnight on trolleys have already been admitted to hospital and are awaiting transfer to beds on other wards.

In general, emergency departments in Ireland are reasonably efficient in and of themselves, and work absolute miracles given the staffing levels they have where they are way short of the required numbers of doctors.

The overcrowding is a broader hospital issue. It would be like checking into a hotel and your room isn’t ready because the last person hadn’t checked out, and they give you a blanket and a seat in the lobby. It wouldn’t be the hotel reception’s fault.

2. We already spend a lot on health so we shouldn’t give “them” more money

This is an adolescent view of the problem. The reality is that the Irish health service has been treating more patients for less money for most of the last decade. Serious healthcare systems all over the world know healthcare costs are spiralling and are making plans to meet that.

The truth is we will need to spend more to stand still, let alone catch up. The overall spend is inevitably going to rise and anyone who thinks it won’t in a population that is booming and ageing is committing a gargantuan act of self-deception.

The cost of drugs is part of it, but so are other interventions such as nutrition, surgery and interventional radiology.

To give one example from my own field, when I started off in gastroenterology 11 years ago people with gut failure tended not to live very long. Nowadays lots of people are living for many years with home parenteral nutrition, which is an amazing, lifegiving intervention but one associated with eye-wateringly expensive costs.

As we strive to provide the best and safest care to patients, expectations have rightly increased too and the tolerance for error or oversight is diminishing.

When I started off as a doctor if someone had a headache they were doing well to get a CT scan and lumbar puncture. Now everyone gets an MRI and a review by a neurologist too.

Liver cancer patients who were previously sent home to die are now more likely to get transplants and cutting edge interventional radiology treatments that prolong their lives greatly.

There are other pitfalls of modern medicine. Ten years ago the CT scanners we used were significantly less powerful and accurate than those in use today. Today’s scanners catch disease earlier but also find a bunch of other abnormalities that previously wouldn’t have been noticed and are usually not significant but have to be taken seriously and followed up.

All western societies are going to have to grasp the nettle of health and care costs in the coming years. This will take an honest and difficult public debate and one from which people of all political persusions will need to dismount from their high horses to take part in.

3. Privatisation is the solution

The private sector has many strengths but has never shown any interest in operating a 24/7 open door emergency system in their own premises, so why are we led to believe by some commentators that they could sort it out in others?

The private sector may well have a role in helping alleviate some pressure on outpatient waiting lists by doing elective, low-acuity work, but it is unlikely that the answer to our acute hospital capacity crisis lies there.

4. If only consultants were available 24/7

They are. In our hospital there are about 25 on call every night, but they will be mostly engaged with the sickest patients, as they should be.

I was in at 10pm on an uncommonly busy New Year’s Eve and encountered our radiologist, anaesthetic, surgical, renal and microbiology consultants in that night as well, dealing with a large number of critically unwell people. Amazingly, my mere presence in the building did not stop the people of south west Dublin becoming ill and coming to the hospital.

A friend and surgical colleague of mine took a mutual shared patient we had seen and discussed earlier that day into theatre at 10pm on Christmas Eve, after a deterioration in his condition. My colleague made it home for 2.30am and after checking Santa had been, was back operating on another emergency case at 10am on Christmas Day.

In case you were wondering I’ve asked him and he didn’t notice any private investigators from Prime Time following him.

If we want more consultants at the front door of the building acting as gatekeepers out of hours then that’s fine, but be advised:

(a) You have to pay them.
(b) You need to cancel all the things they were supposed to be doing the next day in clinics, theatres, endoscopy rooms etc and watch those lists pile up.
(c) They’ll end up admitting very nearly as many people as if not more than some junior doctors.

5. All we need to do is invest in community and primary care

This should be done anyway for its own sake, but its impact on the overcrowding will be modest at best. Most of the patients I admitted last month are on oxygen and fluids, and require intravenous drugs and monitoring. They’re sick. They need to be in hospital because there is no other safe place for them to be cared for.

If we invest in and beef up our primary care services it may reduce the frequency with which they get sick but the inconvenient truth is that the natural history of most chronic diseases of the heart and lungs is that they progress to a point towards the end where very frequent hospital level care is required.

Some politicians likes to think these patients can be cared for in primary care centres but a short walk around a trolley-laden emergency department would be enough to know that the vast majority of the unfortunate people there are most definitely in the right building, just the wrong part of it.

6.  The Angola Myth: sure no politician can sort this out

Well maybe that’s true but we haven’t had a left-wing Minister of Health since the current Labour leader Brendan Howlin led the department from 1992 to 1994 (conflict of interest – I am myself politically left of centre).

The first overnight trolley stay reported in Ireland was in the old Meath Hospital in 1997.

Some of the incumbents like Michael Noonan, Mary Harney, James Reilly and Leo Varadkar would be considered by many observers to be right-wing political figures by Irish standards at least. Correlation doesn’t equal causation, but still….

7.  This only happens in Ireland
8.  It’s not just Ireland

I’m going to take these two myths together. Strictly, the latter is true. This does happen in many other countries and is particularly bad in England and Wales at present.

However the scale and persistence of the problem in Ireland is unmatched. Ultimately what happens overseas is to my mind at least, irrelevant. This is a major problem for the citizens of our republic, who are suffering every night. You wouldn’t not get an engine warning light in your car checked out because your neighbours car was making a funny noise too.

Whether it exists elsewhere is to some extent immaterial, although we should be acutely tuned into efforts to solve the problems overseas to see what can be learned. The same is true of our public health alcohol issues too, by the way.

9. There’s far too much waste in the medical system

This is probably true but this is the system we have chosen as a society. In Ireland we operate an almost US-style medico-legal system with huge payouts. This story has many authors and involves hospitals, insurance companies, the legal profession and the judiciary.

We also run an adversarial system of medical council regulation who have frequently held public show trials for doctors who may or may not be guilty of misconduct or poor standards.

The inevitable and predicted consequence is so-called “defensive medicine” where doctors over-rely on expensive tests and interventions. This is described by some, myself included, as waste but equally is another person’s priceless reassurance.

What is abundantly clear though is that defensive medicine is costly and dangerous and can only be overcome with a better regulatory and legal framework.

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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