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Posed picture of a patient on a trolley Paul Faith

Opinion The key to the trolley crisis lies in a statutory right to access home care

The home care sector is an outdated, bewildering and unfair patchwork of charities, HSE-funded programmes and for-profit carer agencies, writes Dr Domhnall McGlacken-Byrne

THE OTHER DAY in my local coffee shop, I came across a newspaper article reporting the growing number of older people – more than 6,200 – are now waiting on home care supports. In some areas, the waiting times exceeds two years.

After a winter dominated by finger-pointing, and red herrings about staff taking too much Christmas leave, these dry figures were the most interesting thing I read about healthcare in some time.

In particular, I was reminded of a patient I got to know shortly after I started work as a doctor. My team was looking after an elderly gentleman whom I will call Frank, who was admitted to hospital after a bad fall.

Frank* was a retired baker and a father of six, who had a history of heart trouble, chronic back pain and an enlarged prostate.

He had big wispy eyebrows that made him look permanently surprised, spade-like veiny hands that rested on the armrests of his chair and a habit of taking long pauses mid-sentence while he searched for the right word.

After a lengthy period of recuperation, he was well enough to go home but was undeniably more frail than when he came in. He now had a permanent catheter to empty his bladder, and he needed help changing the bag, as well as cleaning and shaving himself.

It was clear that once Frank was discharged home, he and his family would need some help.

After a meeting between Frank’s family, his consultant, his physio and his occupational therapist – an application was made for a Home Care Package, comprising two carer visits per day.

Then the wait began – a wait that was to continue for four months.

Frank spent most of this time obediently sitting out beside his hospital bed on a busy medical ward, reading the newspaper and talking to visitors. One day, coming up to Christmas, I found him sitting out, looking down with his newspaper folded to one side. I cheerily enquired as to how he was feeling.

He looked up, and I realised with a jolt that he was crying. He quietly told me that he had been reading about the trolley crisis, and all the sick people stuck in A&Es waiting to get treated.

He felt guilty. “Here I am, using up a bed for weeks and weeks, and those people are out there and they’re meant to be in hospital,” he said. 

I mumbled that yes, the system could be very frustrating. He shook his head. “Well I don’t know how the system works,” he said, “but I know it’s not working.”

Patchwork Solutions

There is a hidden section of our society which consists of frail, vulnerable people who, like Frank, require assistance with basic tasks such as cleaning themselves, boiling the kettle or cooking dinner.

Even though they are usually older and have several medical problems, this does not necessarily mean that they are ‘sick’, nor that they belong in hospital. But it does mean that to live their lives at home and with dignity, they and their families need some help to get by.

This help is provided by professional carers, who visit daily and keep everything ticking over. Unfortunately, the system for providing this help does not work.

The home care sector is an outdated, unfair and distinctly Irish, bewildering patchwork of for-profit carer agencies, HSE-funded programmes and charities.

If you live in the wrong postcode, or if your family cannot afford private carers, you may wait months or even years for a Home Care Package, or never receive one at all.

An Overflowing Bathtub

In case we forget, the so-called ‘trolley crisis’ of Irish hospitals is not really about trolleys. It is as much about helping people like Frank to get out of the system as about the patients waiting to get in.

A geriatrician who taught me in college, Prof. Des O’Neill, used to invoke the analogy of an overflowing bathtub when describing the Irish health service. 

There are three possible solutions. The first is to turn off the tap: somehow, that is to find a way to prevent people from becoming sick and turning up to their GP’s surgery and A&E.

With an ageing population, this is easier said than done. The Irish tap will continue to flow full-throttle for years to come.

The second thing you can do is increase the size of the bath. This refers to capacity: more beds, more wards, more operating theatres and above all, more staff in the system to make it all happen.

This is urgently needed, for sure, but this will not happen overnight and certainly not without a great deal of effort, money and political leadership. 

The third thing you can do though is to remove the plug, and allow the bath to empty. This means discharging those patients who should not be in hospital – people like Frank.

By far of the three approaches, this is the one that offers the greatest potential to reduce numbers on trolleys in 2019.

The outflow of patients from Irish hospitals is maddeningly inefficient because the plughole is blocked with organisational incoherence and bureaucracy.

Unfortunately, this receives much less coverage than it deserves. Home care was not mentioned in Budget 2019. It is not a political priority. While some extra home care packages have been tacked on to this year’s winter plan, it is nothing close to the substantive sectoral reform that has been promised and is desperately needed.

A Statutory Right
Urgent legislation should be enacted which declares home care provision to be a statutory right: something to which all Irish citizens are entitled, as an extension of the public health system on which we all depend.

This would require the HSE to implement an integrated, state-funded and equitable system of community care provision, guided by the expertise of healthcare professionals, patients and their families.

This is the right thing to do and would ultimately save the taxpayer money. 

Unfortunately, this will not happen unless pressure is applied to the political system by members of society who care about this and who believe that we can do better.

When discussing issues of healthcare in general, we should endeavour to look past the headlines, the recriminations and the distractions and regard healthcare for what it is. 

A human right, guaranteed to all the citizens of a real Republic, young or old, something to which we are all entitled regardless of our income, vulnerabilities or place in society.

After all, someday, all of us will get sick. Someday, if we are lucky we will each enter Shakespeare’s seventh age: we will grow old and frail and will come to need the help of those around us and of the society to which we have contributed all our lives.

Domhnall McGlacken-Byrne is a doctor in the Emergency Department of  Tallaght University Hospital.

*Frank’s name and some other identifying features have been changed to protect his privacy. 

Domhnall McGlacken-Byrne
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