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Professor Ronán Collins: Why do we put up with the state of our hospitals?

The consultant geriatrician says the hospital model of care in Ireland is broken and Sláintecare doesn’t seem fit to fix it.

Professor Rónán Collins Consultant Physician in Geriatric and Stroke Medicine at Tallaght Hospital

“The weariness, the fever, and the fret
Here, where men sit and hear each other groan;”
Keats “Ode to a Nightingale”

A RATHER ILL-CHOSEN ‘worse than Gaza’ was the analogy used by a friend describing a stay in a hospital recently.

There is little doubt that the experience was a challenging one, as it is for many people and especially older people who often functionally decline in hospital, in part at least, because of the hospital environment.

It has been common in my experience for older people to decline cognitively or even be ‘made’ incontinent and immobile by the hospitalisation process. Over the years families have frequently reported their shock at the emaciated functionally dependent ‘shadow of their former selves’ delivered home to them after a hospital stay.

Frustrating for medical teams

This has been a ‘bugbear’ of mine as a doctor both here and in the UK. Geriatricians and specialised multidisciplinary teams, among others, invest much effort in trying to prevent poor outcomes for older people during hospitalisation, though the hospital environment often subverts our efforts, before they have begun.

In my experience over the years, many initiatives to improve the lot for patients in hospitals have been thwarted by a lack of resource, priority or the basic inability to put ‘ourselves in another person’s shoes’.

These poor environments are tolerated I’d imagine, as people, including healthcare workers, are increasingly conditioned to expect that our public teaching hospitals be of a poor estate, second rate, not aspiring to much and certainly not as good as a private one.

Our public teaching hospital system, once often considered the best place to be cared for, is now falling ever behind the curve in terms of accommodation and indeed technology. This gap is soon to be widened if Sláintecare succeeds and drives income from our public system to deliver the tiers of ‘where I choose to go to be treated and where I have to go to be treated’.

Once the sought-after preferred employment for healthcare professionals, our public teaching hospitals, are increasingly being abandoned for better prospects, and working environments, abroad or in the private sector.

We have over 700 vacant consultant posts in the country and recruitment of nursing staff is a particular ongoing challenge. Poor working environments are an important factor.

Many if not most of our public hospitals have sizeable proportions of their bed stock, below any reasonable standard of acceptable accommodation to care for patients, especially older ones. Trying to have highly sensitive discussions with any type of privacy is impossible in six-bedded bays.

Dehumanising

It is fundamentally dehumanising on patients, staff and those around them, for our sickest patients to have to be toileted, or have their painful odorous wounds dressed in such a public fashion in open bays with the ubiquitous and useless plasticated curtain drawn around.

It is horrendously embarrassing and undignified to be breaking bad news or assessing patient capacity, in such arenas and in many situations that is the only choice for staff. It is dangerous from an infection control perspective to allow such accommodation arrangements to continue, as the recent pandemic exposed, and the ‘cohorting’ solutions so recently employed for those infected or indeed just deemed ‘contacts’ of an infectious disease, is fraught with medical risk.

One cannot underestimate the psychological effect of the hospital experience on patients. Many have remarked to me over the years of their trauma on overhearing upsetting conversations or witnessing distressing care episodes, of feeling humiliated, being exhausted from continuous sleep deprivation or frightened by the experience of sharing close sleeping quarters with delirious or dying patients. It is often a job to try to convince patients to stay when medically needed, because of the environment.

I remember years ago pointing out the inadequate space between beds to a visiting inspection in a hospital I was visiting, for my concerns to be dismissed as not on the checklist of the inspection.

The fact that nurses and health care assistants in our hospitals manage to look after patients in such conditions, treading the narrow paths between beds, floor cleaning cones, Zimmer frames and manoeuvre drug trollies, hoists and dinners into position or attend to people, is a constant source of wonder.

I frequently see the frustration etched on their faces. Our hospitals are too frequently also an unacceptable working environment. Yes, there are times when we need open-unit-style care for those most critically ill but even that needs proper design.

To add to the woes most of our hospitals still have 1950s B&B style shared bathroom facilities that no one would dare book into now, never mind use in a healthcare setting with the risk of cross-infection. The privacy needed to be able to vomit or have diarrhoea, or not ‘make it in time’, with some form of dignity, denied people.

Unacceptable conditions

There is rarely space for patients just to be able to cry or express emotion for themselves or to others, in a secure private environment. Add to that the lack of amenity where many people still have no access to an individualised radio or TV, or room enough for the most basic of rights, to walk. Is it any wonder patients can be agitated, confused or distressed in such surroundings.

Imagine yourself strapped in on a long-haul flight without amenity, without end.

From a staff hygiene point of view, many of our hospitals still have no showering or changing facilities. It is still, after all these years, somewhat bizarre to me having worked in a pharmaceutical plant environment with dangerous substances, where you showered and changed in and showered and changed out, that this basic principle is not mandated and resourced across our hospital system, for clinical staff who work with the most dangerous of substances in the most dangerous of environments. Most Irish hospital staff are bringing their bug-infested work clothes home to contaminate their families and their domestic washing machines.

I listened recently while callers into ‘Liveline’ recounted how their loved one’s valuables went missing while in hospital, wedding rings, lockets, the individual insignia of treasured lives.

You can add to those, from my discussions with colleagues around the country, the loss of countless invaluable hearing aids, dentures etc. that start the process of disabling our older people in hospital, now left unable to communicate or eat properly.

In truth we have neither the mechanism nor facilities to secure people’s personal belongings in most of our hospitals and there is, unfortunately, an acceptance that their loss is almost an inevitability now.

It doesn’t seem to really matter when we have insurance it seems, but these things are not easily replaced if they can be at all.

Why do we tolerate this?

I have witnessed these awful environments across countless of our hospitals over many years and change is urgently needed.

There is surely something seriously wrong when I find myself worrying about the effect the hospital environment will have on patients almost as much as the illness that brought them in.

Many hospitals, my own included, have plans in place to improve estate but desperately need the resourcing and priority at a government level to realise those plans. Never mind rounds of applause, or indeed bank holidays, if you want to help frontline healthcare workers as well as your loved ones and yourselves while you’re at it, demand change.

Ask of our hospital inspectors would they be happy to see a loved one spend a few nights there, and maybe then we will get action on an agreed national set of minimum standards for hospital accommodation and design.

Sláintecare is correct and ambitious in its aim to provide more care in the community, but that won’t solve our hospital problem. Having witnessed the primary care trust funding model of acute hospital services in the UK, I see the dangers of a further stripping of resources in manpower and funding from hospitals to the community.

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In truth, the overall model of funding must be one of an integrated approach with our hospitals as the centrepiece of our communities’ acute and more complex healthcare needs in order to build an effective responsive health service.

This will be a massive task to refit our hospitals with a patient-centred, age-inclusive and infection control emphasis but it is a very necessary one that is well overdue. We need real social solidarity with our teaching public hospital system, where we actually train our healthcare professionals, and deal with the most seriously ill patients and strive to set standards of care.

That also means encouraging insured patients to come to us for their healthcare and help fund a system for all. I’ll ‘sign up’ to a Sláintecare vision when I see the politicians who advocate it, coming to our public teaching hospitals for their personal healthcare needs and using the insurance they can easily afford, to help fund them.

Professor Rónán Collins MD FRCP (Lond) FRCPI FESO is a Consultant Physician in Geriatric and Stroke Medicine at Tallaght Hospital. Follow him @ronancollins7.

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About the author:

Professor Rónán Collins  / Consultant Physician in Geriatric and Stroke Medicine at Tallaght Hospital

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