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Opinion: Changing the model of hospital care could help solve the trolley crisis

Why is the HSE doing the same thing repeatedly but expecting to get different results? writes Dr Cathal O’Sullivan

Dr Cathal O'Sullivan

IT IS WIDELY acknowledged that the Irish hospital system is dysfunctional.

The underlying reasons for this dysfunction are rarely identified correctly though.

Sadly, despite claims to the contrary, resolution of the recent nurse’s strike will do little or nothing for patients when it comes to trolley waits, outpatient clinic delays and access to the hospital system generally.

When it comes to analysing the underlying causes for the mess that is Irish hospital medicine, one needs to focus on acute medical care. Dysfunction in this area is responsible in large part for the problems affecting the entire hospital system.

To solve the problems of hospital medicine in Ireland, therefore, one needs to separate out the provision of acute, urgent, unscheduled medical care from all other types of care, in particular, specialist medical care.

In management theory, when one is faced with what appears to be an intractable problem, one usually finds that the underlying ‘structure’ is defective.

In the case of Irish hospital medicine, the structural defect is the model of care.

Yet the HSE sticks to the current model of care delivery, despite all the evidence of its ineffectiveness, highlighting the complete lack of leadership, vision and management expertise in the organisation.

Indeed, the behaviour of the HSE in this regard is best typified by the well-known quote, commonly misattributed to Einstein. 

The definition of insanity is repeating the same experiment over and over again but expecting a different result.

The one thing that the HSE has demonstrated unequivocally is that throwing ever more money at the problem will not solve the problems. 

I’ll outline a model of care that is built around patient need, which I have seen work successfully in a hospital I worked in, in Boston.

By changing the model of care, the daily problems of overcrowding in A&E departments, prolonged trolley waits, outpatient waiting times can be resolved.

The model of care delivered by consultant physicians in Ireland reflects the compromise by which they are expected to provide both general medical care, along with subspecialist care.

That this compromise fails to deliver prompt, high quality, care should come as no surprise to anyone.

Instead, what we see is that both subspecialty care is poor (with current outpatient waiting lists of more than 500,000) and general medical care is also poor, (mayhem in A&E departments and people on trolleys.) 

This current model of care can also be seen to be the driving force behind the emigration of so many Irish trained doctors. So reforming it could help with Irish medical graduate retention and recruitment too. 

The current model

In many Irish hospitals a single team, comprising a consultant physician and 3 or 4 junior doctors, will be ‘on-call’ for a 24 hour period, every 6th, 7th or 8th day depending on the number of medical consultants employed.

During this period, that team takes responsibility for all medical admissions to the hospital.

One frequently hears refrains from junior doctors following their on-call ‘we were slammed!’, ‘I have 34 patients!’. These problems indicate that there will also be a  negative impact on the quality of patient care.

Over the following 6, 7 or 8 days the team whittle down their patient numbers until the team has fewer patients and then it starts all over again.

This delivery of care model, built as it is around consultants schedules, is the key structural defect in the Irish hospital system.

Such a model of care, whereby patients are admitted to a particular consultant, rather than a medical service, underpins the grossly inefficient Monday to Friday style operation of our hospital system, not to mention the compromise in quality of care. 

Put another way, we can characterise the Irish hospital system as ‘the wrong (type of) doctors, delivering the wrong model of care, in inefficiently run hospitals’.

But it doesn’t have to be this way.

A different model

The first step is to separate subspecialist medical care from acute medical care, that is to separate specialist care from general care.

This means appointing consultants whose sole role is that of providing acute care, without the competing demands of their subspecialty.

Such generalist doctors are termed hospitalists. Like most good ideas, this is by no means a new idea.

Indeed, the Hanley Report in 2003 considered advocating the creation of such consultant posts but was ‘persuaded’ against this by the doctors. 

Through the appointment of hospitalists, the model of care delivered can be changed. In particular, the new model of care envisages the replacement of the medical consultant lead team with instead a medical service.

Each medical service would operate a 7-day service, with each of the individual medical services admitting, and discharging, patients 7 days a week.

The model provides for greater flexibility for both consultants and junior doctors whilst also ensuring continuity and better quality of care for patients.

For example, hospitalists may wish to mirror the nurses by working 4 days on and 3 days off.

In my opinion, the preferred option would be for them to work ‘week on/week off’.

The obvious difference between this model and the existing model of care is that this new model is built around the needs of patients. 

While the existing system is built around doctors’ schedules and competing demands.

The benefits of the proposed system are manifold.

Average length of stay

The 7-day service should lead to a significant reduction in the average length of stay (ALOS) of patients, doctors working seven days a week would discharge patients at the weekend.

This will improve the efficiency of the hospital, in turn, creating additional bed capacity.

Raising the level of discharges on the weekend to that currently seen on weekdays would result in an estimated reduction in the ALOS, from 6.3 days to 5.2 days.

That should lead to an estimated 20% increase in bed availability, amounting to some 2400 beds.

One would anticipate an improvement in the discharge rates during the week also leading to a further fall in ALOS and a commensurate rise in bed availability.

Given that our spendthrift health minister, Simon Harris, plans on spending €3.2bn of taxpayer money on opening an additional 2500 beds over the next 10 years, the above increased bed availability highlights the merits of a move to a 7 day hospital medical service, possible through the introduction of hospitalists, quite apart from the other benefits listed below.

Recruitment and retention

For doctors, the most obvious benefit is the flexibility inherent in the hospitalist grade post.

By offering better work/life balance, such posts have the potential to attract Irish doctors back from overseas.

The modular aspect of these same posts also make them much more attractive to female medical graduates with young families, and indeed other doctors who may wish to continue to practice hospital medicine but do not wish to do so full-time.

Why not try it?

This new model of care should be introduced in parallel to the existing model of care in a number of pilot sites.

The initial pilot should take place in hospitals with the longest ALOS and highest trolley numbers, perhaps, for example, Cork University Hospital in the news this week after the INMO said that 81 patients were on trolleys.

This pilot approach represents a low-risk way to assess the merits of the scheme as advocated.

In summary, the current crisis in Irish medicine results from the mismatch of employing part-time general medicine physicians to deliver care to acutely unwell patients 24/7.

The solution is to match medical staffing to the needs of patients. This can be readily achieved through the introduction and deployment of hospitalist doctors.

This is the key step in switching from the current, failing, model of care to the much more efficient, proposed model of care.

This new model, if properly implemented should lead to a substantial increase in bed capacity through reduced ALOS, while at the same time leading to better quality of care for patients.

Cathal O’Sullivan MD, is trained in general medicine, infectious diseases and clinical microbiology. He is a consultant Regional Microbiologist in the Midlands. 

He trained and worked in the USA (Mayo Clinic, National Institutes of Health, UAB and Tuft NEMC),  in the UK (Barts and the Royal London Hospital) as well as Ireland.

He also holds a Masters in Business Administration from Trinity College Dublin. 

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About the author:

Dr Cathal O'Sullivan

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